poster
ARIR 3 rd International Conference
on Respiratory Physiotherapy
Rimini, 10-12 marzo 2016
Di seguito riportiamo gli abstract dei 2 poster vincitori e, a seguire, quelli che hanno ottenuto un punteggio
maggiore di 5 alla valutazione di un panel di esperti dedicato (rating 1-10).
La sequenza di esposizione è in ordine alfabetico, non di risultato alla valutazione.
POSTER VINCITORE “PREMIO A VALENZA SCIENTIFICA”
S. Becchiati
Università degli Studi di Milano, CdL Fisioterapia; Fondazione IRCCS
Cà Granda Ospedale
S. Gambazza, R. Guarise, A. Brivio, F. Carta, C. Colombo
Maggiore Policlinico, Centro di Riferimento Regionale per la Fibrosi Cistica
(CRRFC)
Background: Although some studies already showed the efficacy
of positive expiratory pressure (PEP) as airway clearance technique
[1], yet it is not clearly understood what is the impact of this technique on pulmonary ventilation inhomogeneity (VI), a typical feature
of patients with Cystic Fibrosis (CF). In this context, measures of VI
– derived from multiple-breath washout (MBW) – have grown in
prominence as an alternative to conventional spirometry due to
their sensitivity, shown by a number of cross-sectional and longitudinal studies, to early changes in peripheral airways [2].
Aim: To investigate how PEP-Mask affects ventilation inhomogeneity in clinically stable patients with mild to moderate CF, by the
change in Sacin, LCI2.5 and Scond indeces derived from nitrogen
multiple-breath washout test (N2-MBW).
Methods: A cross-over randomized controlled trial was run at the
CF Centre of Milan. Patients were enrolled at the end of an intravenous antibiotic. After performing spirometry before being discharged, as per clinical practice, and after checking the inclusion
criteria, they were asked to withheld their usual bronchodilator
therapy. Patients underwent the study procedure, consisting in four
N2-MBW, one before and one after the intervention with PEP-Mask,
either standard or sham, during two subsequent mornings (Figure
1). The order of application was randomly assigned. The standard
intervention with PEP-Mask was performed according to the protocol used at the CF Centre [3], that is 1 min of breaths with a slightly active expiration through the mask, repeated for 10 times, in a
forward lean position with elbows rested on a table; the expiratory
resistor had an internal diameter such as to ensure a pressure
range, controlled by a manometer, between 10 and 20 cmH20.
Between repetitions (30 sec) 3 huffs through standard mouthpiece
22
Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
tubing were performed (forced expiration from TLC to FRC) together with and one cough. The sham intervention was performed in
the same way, caring to use an expiratory resistor with an internal
diameter such as to ensure less than 10 cmH20 pressure. Wet
sputum was collected at the end of every procedure as secondary
outcome measure while SpO2 was registered throughout the procedure as security measure. Physiotherapists (PTs) performing nitrogen multiple-breath washout test were blinded to treatment allocation as well as PTs performing standard or sham PEP were
blinded to LCI results. Patients were considered blinded to the purpose of the study. Sample size has been set at 30 patients in order
to give estimate of treatment variance and determine a larger sample size based on feasibility criteria as well.
Results: Since the study is still ongoing, treatment arms are blinded, and A and B just describe the two interventions performed.
Data are displayed as mean (standard deviation) (Table 1). Sacin
reached an average value of 0.22 (0.04) units/litre (pre) and 0.23
(0.04) units/litre (post) in treatment A, while it gave 0.21 (0.01)
units/litre (pre) and 0.23 (0.03) units/litre (post) in treatment B.
Scond remained unchanged before and after the intervention in both
treatment arms [0.10 (0.02) units/litre in treatment A and 0.10
(0.03) units/litre in treatment B]. Mean LCI2.5 was 18.04 (3.73)
(pre) and 17.95 (4.14) (post) in treatment A, differently than 17.61
(3.86) (pre) and 17.35 (3.72) (post) in treatment B. Sputum volume
throughout the procedure reached a mean weight of 5.53 (4.07) g
(treatment A) and 3.70 (2.99) g (treatment B).
Conclusions: Although it is not possible to draw any conclusion on
the efficacy of PEP-Mask therapy on distribution of ventilation in
small airways (Sacin), this primary outcome appears to be enough
Day 1
Randomization
Short-term effect of positive expiratory
pressure on ventilation inhomogeneity
in patients with Cystic Fibrosis
N2-MBW
A
Day 2
N2-MBW
N2-MBW
B
N2-MBW
Time
N2-MBW
B
N2-MBW
N2-MBW
Figure 1 Temporal sequence of the procedure.
A
N2-MBW
Table 1 N2-MBW data.
N2-MBW (before PEP-Mask)
LCI2.5
Scond,
units/litre
N2-MBW (after PEP-Mask)
Sacin,
units/litre
LCI2.5
Scond,
units/litre
Sacin,
units/litre
Wet sputum
weight, g
Intervention A
18.04 ± 3.73 0.10 ± 0.02
0.22 ± 0.04 17.95 ± 4.14 0.10 ± 0.02
0.23 ± 0.04
5.53 ± 4.07
Intervention B
17.61 ± 3.86 0.10 ± 0.03
0.21 ± 0.01 17.35 ± 3.72 0.10 ± 0.03
0.23 ± 0.03
3.70 ± 2.99
sensitive to detect differences in the distribution of ventilation in patients with CF, compared to FEV1 alone. Despite minimal clinical important difference for N2-MBW indices was not yet established,
these preliminary data provide an insight into good practice for respiratory physiotherapists. Concluding the ongoing study becomes
essential to prove PEP-MASK efficacy on small airways and to probe
the N2-MBW need in routine clinical setting. Furthermore, efforts for
inclusion and standardization of these indices might help interventional studies research and improve CF early lung management.
References
[1] Pfleger A, Steinbacher M, Schwantzer G, Weinhandl E, Wagner
M, Eber E. Short-term effects of physiotherapy on ventilation
inhomogeneity in cystic fibrosis patients with a wide range of
lung disease severity. J Cyst Fibros 2015;14:627-631.
[2] Al-Khathlan NA. The involvement of the lung periphery in cystic
fibrosis: an exploration using multiple-breath nitrogen washout
and helium-3 diffusion magnetic resonance. Department of Infection, Immunity and Inflammation, Division of Child Health,
University of Leicester. https://lra.le.ac.uk/bitstream/2381/325
13/1/2015ALKHATHLANNPhD.pdf. Accessed on September
2015.
[3] Falk M, Kelstrup M, Andersen JB, Kinoshita T, Falk P, Støvring S,
Gøthgen I. Improving the ketchup bottle method with positive expiratory pressure, PEP, in cystic fibrosis. Eur J Respir Dis
1984;65:423-432.
POSTER VINCITORE “PREMIO A VALENZA ORGANIZZATIVA”
Hospital-community integration in als
Respiratory Care: the home need.
A telematics multicenter survey
B. Garabelli, A. Lizio, E. De Mattia, M. Iatomasi, F. Rao, C. Lunetta,
V. Sansone
NeMo Clinical Centre, Fondazione Serena Onlus, Niguarda Hospital, Milan
S. Cattaneo, M. Messina
Rehabilitation Department of S.Antonio Abate Hospital, ASST Valle Olona,
Gallarate
e-mail: Barbara Garabelli, barbara.garabelli87@gmail.com
Background: ALS is a rare, neurodegenerative fatal disease. Hub
and Spoke Centres in Italy provide multidisciplinary care pathways
specifically calibrated to ALS. Protected discharges and admissions guarantee care continuity, but home care is improvable, especially for the respiratory management.
Aim: To investigate the need of Respiratory Care (RC) for ALS patients with Non Invasive (NIV) or Invasive Ventilation (IMV) and
cough-machine at home, including a patient-caregiver subjective
assessment of available services.
Method: Prior to consent, an on-line survey was distributed to ALS
patients without cognitive impairment attending two multidisciplinary centres: Nemo in Milan (tertiary centre), and S.Antonio Abate
Hospital in Gallarate (secondary centre). We enrolled 103 patients
(53% Nemo, 47% Gallarate) between June 2014 and December
2015. 91% were from Lombardy, 9% from other regions. Descriptive analysis and correlations between categories were obtained.
Results: 80% patients used mechanical ventilation, 62% NIV, 38%
IMV. 92% required one or more caregivers to manage ventilation.
85% had a cough-machine at home. 87% needed one caregiver or
more for the management of the machine, 17% had constant trouble with secretion clearance while in 33% this was challenging
only during respiratory infections. Only 42% patients thought their
family doctors knew about the disease adequately, 37% received
no home care. None had home respiratory care assistance (a Pulmonologist and/or a Respiratory Therapist (RT) integrated in the
home multidisciplinary team). Only 46% patients never had Complicated Respiratory Infections (CRI) requiring antibiotics, 54% at
least one, 35% several. We sought for some correlations between
CRI and cough machine or mechanical ventilation use. Patients using cough-machines > 30 minutes/day and patients on ventilation
for > 16 hours/day were those having a higher incidence of CRI
(p < 0,05 and p < 0,0001 respectively) (Figure 1).
Ventilator-dependent patients > 16h had a higher incidence of
Emergency Call (EC) (p < 0,0001). Patients who had at least one
CRI had 13 times the relative risk to resort to EC compared to stable patients with no CRI (p < 0,0001) (Figure 2). Trying to counteract infection onset we could reduce risk of EC of 52%. This result
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
23
Figure 1 CRI trend in relation to cough machine and NIV use.
Figure 2 Emergency calls in relation to NIV use and CRI.
Useless
Maybe
Probably Yes
Absolutely Yes
Figure 3 Patients’ opinion on CRI prevention with a RT home
interventions.
also applies excluding IMV patients, considering the influence of
tracheostomy on infection onset. Once NIV patients have had at
least one CRI, the risk of EC becomes 5 times (p < 0,05). Counteracting infection onset we could reduce EC of 29% in NIV patients.
76% caregivers would like a better systematic specialist interaction to manage home RC. 84% would appreciate RT home visits,
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Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
89% felt they would have prevented CRI if a RT had been in their
homes (Figure 3).
Conclusions: At present interviewed ALS patients’ caregivers manage
home respiratory assistance almost alone. Adequate RC in ALS patients’ home is lacking and should be improved, especially for patients
in IMV, NIV > 16 hours/day and for cough-machine strong users.
Role of respiratory therapist in an adult
bronchiectasis clinic
Respiratory effects of specific lumbopelvic cylinder muscle training in obese men
S. Annoni, S.C. Zucchetti, E. Simonetta, A. Stainer, F. D’Arcangelo,
E. Oggionni, P. Faverio, A. Pesci, S. Aliberti
Scuola di Medicina e Chirurgia, Università degli Studi di Milano Bicocca
Clinica Pneumologica, AO San Gerardo, Monza
e-mail: sarannoni@virgilio.it
E. Bezzoli, L. Pianta, A. Salvadori, M. Mascheroni, L. Piccinno,
P. Capodaglio
Istituto Auxologico Italiano, Piancavallo (VB) Italy
D. Andreott
Physiotherapy, SMARTERehab, Gordola, Switzerland
L. Puricelli
Università degli Studi dell’Insubria, Varese, Italy
e-mail: e.bezzoli@auxologico.it
Background: Bronchiectasis causes chronic cough, sputum production and recurrent respiratory infections [1]. Although airway
clearance techniques seem to be effective in removing secretions
and improving patients’ symptoms [2,3], evidence is scarce.
Aim: To evaluate the impact of respiratory therapy on quality of life,
cough and exacerbation frequency in adult patients with bronchiectasis.
Methods and Materials: This was an observational, prospective
study enrolling adult outpatients with non-CF bronchiectasis referring to the tertiary care bronchiectasis clinic of the San Gerardo
University Hospital, Monza, Italy, from 1st January 2014 to 31st
August 2015. Patients were reported by pneumologist to the attention of the respiratory therapist according to previously agreed criteria. Evaluations (E) included: E1) first assessment, including clinical examination, educational program and check-up of nebulized
therapy and equipment. Patients had to fill out a diary regarding
respiratory symptoms for 1 or 2 weeks to find out usual being.
E2) Choice and teaching of airway clearance techniques according
to patient’s skills and preferences. Patient had to fill out the diary
until next session to evaluate treatment effectiveness. E3) Assess
patient education in self-management of the learned technique or
start over with another technique. E4) Follow up at 6 months. Patient was also provided with some booklets about bronchiectasis
features, management during exacerbation, method and timing of
the learned technique and hygienic habits.
Outcome measures: Leicester Cough Questionnaire (LCQ), St.
George’s Respiratory Questionnaire (SGRQ) from E1 to E4. Number
of exacerbations 6 months after first assessment compared to 6
months before first assessment. Patient satisfaction was also recorded by purpose-built questionnaire.
Results: Among the 59 patients referring to respiratory therapist,
17 were excluded (6 were lost to follow up, 5 underwent long-term
antibiotic therapy, 6 needed only the educational session). The final
population accounted for 42 patients (median age 68 years, 41%
males). An improvement in quality of life (–2.6 median points
SGRQ), cough symptom (+ 2.15 median points LCQ) and number
of exacerbations (20 out of 42 had lower number of exacerbations)
was registered after the intervention in comparison to baseline.
There was a fair level of satisfaction 6 months after first evaluation.
Conclusion: These data confirm the crucial role played by respiratory physiotherapy as treatment of adult patients with bronchiectasis in the context of a multidisciplinary approach.
References
[1] Ten Hacken NH, Kerstjens HA. Bronchiectasis Search date
APRIL 2011 BMJ Clin Evid. Aug 16; 2011.
[2] Dentice R. Airway clearance physiotherapy improves quality of
life in patients with bronchiectasis. Aust J Physiother
2009;55(4):285.
[3] Flude LJ, Agent P, Bilton D. Chest physiotherapy techniques in
bronchiectasis. Clin Chest Med 2012;33(2):351-61.
Background: It is known that obese subjects may have decreased
pulmonary volume [1]. The major respiratory complications of obesity include a heightened demand for ventilation, an elevated workload for breathing, respiratory muscle inefficiency and diminished
respiratory compliance [1]. Obese men have an android adipose
tissue distribution and in standing their center of mass is anterior
to their base of support [2], provoking an alteration in automatic
trunk muscle activation [3]. The lumbo-pelvic cylinder musculature
influences breathing, postural control and lumbar stability by enhancing intra-abdominal pressure [4-9] and increasing the diaphragmatic oppositional area [10].
Aims: The purpose of the present study is to evaluate whether the
specific motor control exercises for the lumbar-pelvic cylinder
muscles are able to modify respiratory function in obese men
greater than general strengthening exercises.
Methods: Twenty obese male patients with forced vital capacity
(FVC) ≤ 80% were randomized into two groups. Five days per week
for three consecutive weeks both groups performed one session of
endurance training using a bicycle Ergometer and took part in a
30-minute group exercise session. The experimental group (SEG)
performed specific exercises aimed at increasing perception and
activation of the lumbar-pelvic musculature. The control group (CG)
performed general strengthening exercises. All subjects were evaluated by: spirometry, walking test (6MWT), thoracic excursion,
maximal respiratory pressure. Oxygen Cost Diagram (OCD) was
administrated for the evaluation of dyspnea.
Results: The SEG had significant improvements in: FVC (5,2% p =
0,038), slow vital capacity (VC) (p = 0,029), RV to TLC ratio (11.8%
p = 0,033), maximal voluntary ventilation (MVV) (11.9% p = 0,049),
MEP (9,3% p = 0,009), thoracic excursion (92.5% p ≤ 0,0001),
OCD (63,6 % p ≤ 0,0001) and 6MWT distance (15% p = 0,007).
The CG showed improvement in 6MWT distance (11% p = 0,001)
and OCD (47.2% p ≤ 0,0001). The MEP value worsened only in
absolute terms, while the thoracic excursion remained unchanged.
Conclusions: The study suggests that in obese men respiratory
function may benefit from specific exercises. This study was a pilot
study and is limited by low numbers and a lack of power calculation for a primary outcome measure. Therefore, the statistics
should be interpreted with caution.
References
[1] Parameswaran, DC Todd, Soth M. Altered respiratory physiology
in obesity. Can Respir J 2006;13(4):203-210.
[2] Clark KN. Balance and Strength Training for Obese Individuals.
ACSM’S Health & Fitness Journal. January/February 2004.
[3] O’Sullivan PB, Beales DJ, Beetham JA, et al. Altered motor control strategies in subjects with Sacroiliac Joint Pain during the
Active Straight-Leg-Raise Test. Spine. 2002;27(1):E1-E8.
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
25
[4] Cresswell A, Grundstrom H, Thorstensson A. Observations on
intraabdominal pressure and patterns of abdominal intramuscular activity in man. Acta Physiol Scand 1992;144:409-418.
[5] Hodges PW, Gurfinkel VS, Brumagne S, et al. Coexistence of
stability and mobility in postural control: evidence from postural
compensation for respiration. Exp Brain Res, 2002;144:293-302.
[6] Hodges PW, Eriksson AE, Shirley D, et al. Intraabdominal pressure increases stiffness of the lumbar spine. J Biomech.
2005;38(9):1873-1880.
[7] Hodges P, Sapsford R, Pengel L. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn.
2007;26:362-371.
[8] Malatova R, Drevikovska P. Testing procedures for abdominal
muscles using the muscle dynamometer. Proc Inst Mech Eng H.
2009; 223(8):1041-1048.
[9] Kolar P, Sulc J, Kyncl M, et al. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol. 2010;109(4):1064-1071.
[10] De Troyer A, Wilson TA. Mechanism of the increased rib cage
expansion produced by the diaphragm with abdominal support. J Appl Physiol 2015;118:989-995.
Respiratory muscle strength, lung volume
restriction and cough efficacy in DM1:
Impact on exercise performance
E. De Mattia, A. Lizio, B. Garabelli, M. Iatomasi, M. Gualandris,
V. Gatti, F. Rao, V. Sansone
NeMo Clinical Centre, Fondazione Serena Onlus, Niguarda Hospital, Milan
e-mail: elisa.demattia@centrocliniconemo.it
Background: Myotonic dystrophy type 1 (DM1) is a slowly progressive multisystem disease with the main clinical features of muscular
weakness, wasting and myotonia. Many subjects with DM1 describe
limitations in ambulation, that influences activities in daily life and
enables participation. Moreover, respiratory involvement is very common in DM1 and it leads to hypercapnia and lung volume restriction.
Aim: To study correlation of different spirometry and respiratory
muscle strength variables with variables of Six minutes walk
(6MWT) and Ten meters walk (10T) tests in a DM1 population.
Methods: In our prospective study, 28 consecutive patients
(42,51±10,08 years), affected by DM1 without respiratory failure,
were enrolled from February 2015 to December 2015. We assessed the impact of respiratory muscle strength, lung volume restriction and cough efficacy – evaluated with the measure of Maximal Inspiratory and Expiratory Pressure (MIP and MEP), Forced Vital Capacity (FVC), and Peak cough Expiratory Flow (PcEF) – on
exercise performance – evaluated with two clinical walking field
tests (6MWT and 10T). Respiratory muscle tests, spirometry and
6MWT were performed according to the ATS guidelines [1-3]. 10T
was performed as described by Watson [4]. Correlation between
respiratory function variables and walking tests variables was assessed using the Pearson correlation coefficient and the non-parametric Spearman rank correlation coefficient, as appropriate, for
univariate analysis and multivariable regression model adjusted for
age, sex and BMI for multivariable analysis. A p-value < 0.05 was
considered significantly.
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Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
Results: FVC significantly correlated with 6MWT distance (in ortostatism: r=0,37692 for % predicted, and r=0,63573 for absolute
value; in clinostatism: r=0,33228 for % predicted, and r=0,69638
for absolute value) and 10T time (in ortostatism: r=-0,50608 for %
predicted, and r=–0,66168 for absolute value; in clinostatism:
r=–0,36528 for % predicted, and r=–0,68935 for absolute value).
MEP also significantly correlated both with 6MWT distance
(r=0,69362) and 10T time (r=–0,64968). Instead, MIP and PcEF
significantly correlated only with 6MWT distance (r=0,46826 and
r=0,49643, respectively), but not with 10T time.
Conclusions: At our knowledge, this is the first study showing correlation of respiratory muscle weakness and lung volume restriction with exercise performance in DM1. In our DM1 patients, respiratory function significantly correlates with walking tests variables. Basic differences between 6MWT and 10T could explain why
MIP and PcEF correlate only with 6MWT distance but not with 10T
time. Indeed, the 6MWT evaluates the global and integrated responses of all the systems involved during exercise, while the 10T
assesses just walking speed over a short distance.
References
[1] ATS/ERS Statement on respiratory muscle testing. Am J Respir
Crit Care Med 2002 Aug 15;166(4):518-624
[2] ATS/ERS Task force: standardization of lung function testing.
Eur Respir J 2005;26:319-338.
[3] ATS statement: Guidelines for the six minute walk test. Am J
Respir Crit Care Med 2002;166:11-117.
[4] W
atson MJ. Refining the ten-metre walking test for use with neurologically impaired people. Physiotherapy 2002;88(7):386-397.
Ventilation inhomogeneity and lung
impairment in children with primary
immunodeficiency: an observational study
R. Guarise, S. Gambazza, M. Foà, M.C. Russo, A. Brivio, C. Colombo
Centro di Riferimento Regionale per la Fibrosi Cistica (CRRFC),
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
P. Pavesi, R.M. Dellepiane
UOS Immunologia Pediatrica, Clinica Pediatrica Media Intensità di Cura,
Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
L. Dell’Era
UOC Pronto Soccorso, Pediatria Ambulatoriale, DH/MAC, Fondazione
IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano
I.M. Borzani
UOC Radiologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milano
e-mail: rguari@gmail.com
Background: Lung Clearance Index (LCI) is a measure of abnormal
ventilation distribution derived from the multiple breath inert gas
washout (MBW) technique for whom respiratory physiotherapy has
increased interest in the last decade. LCI has been reported as a
better predictor than FEV1 to assess early lung damage in patients
with Cystic Fibrosis according to computed tomography (CT) findings [1,2]. So far no study has investigated the presence of pulmonary ventilation inhomogeneity in children with Primary Immunodeficiencies (PID).
Aim: To detect ventilation inhomogeneity by nitrogen MBW technique and to assess clinical utility of LCI compared to the traditional spirometry and CT scan assessment in children with PID.
Methods: All children with PID referring to our clinic were recruited
from November 2015 to February 2016 during a scheduled followup. Spirometry, body pletismography, nitrogen MBW test were performed. CT scan was also performed in those children who had not
one in the year before. LCI percentage of predicted and upper limit
of normality (ULN) were calculated according to paediatric reference equations [3]. CT scans were evaluated according to Bhalla
score. Spearman correlation was calculated between LCI, FEV1 and
FVC. Fisher’s exact test was used to assess the association
between LCI below/above ULN and Bhalla score (positive/negative).
Sample characteristics are presented as mean(sd).
Results: Twelve children with PID (7 Common Variable Immunodeficiencies (CVID), 4 X-linked Agammaglobulinemia (XLA), 1 X-linked
Hyper-IgM, 1 IgA deficiency (IgAD), 1 IgG subclass deficiency),
7 female, aged 12(2)yrs were recruited. FEV1%pred. (114.9
(18.1)%) and a FVC (113.2(15)%) were normal in all patients.
Bhalla score detected abnormalities in 4 patients (3 CVID, 1 IgAD)
with an average value of 0.8(2)%. LCI reached an average value of
7.24(0.67) (6.33-8.25). Four children (2 XLA, 1 CVID, 1 IgAD) presented an LCI higher than ULN, 2 of which (1 CVID, 1 IgAD) had
altered Bhalla score values. No association was found between LCI
and CT scan scoring.
Conclusions: Unlike studies carried in patients with cystic fibrosis,
LCI doesn’t correlate with CT score in patients with PID. However it
seems that LCI changes earlier than FEV1 in patients with lung injury.
More studies on a large cohort of patients with PID are needed to
assess the sensitivity of LCI versus FEV1 to detect early lung disease
and to assess its utility in respiratory physioterapy clinical practice.
References
[1] Gustafsson PM, De Jong P, Tiddens H, Lindblad A. Multiplebreath inert gas washout and spirometry versus structural lung
disease in cystic fibrosis. Thorax 2008;63(2):129-134.
[2] Owens CM1, Aurora P, Stanojevic S, Bush A, Wade A, Oliver C,
Calder A, Price J, Carr SB, Shankar A, Stocks J. Lung Clearance
Index and HRCT are complementary markers of lung abnormalities in young children with CF. Thorax 2011;66(6):481-488.
[3] L um S, Stocks J, Stanojevic S, Wade A, Robinson P, Gustafsson P,
Meghan Brown M, Paul Aurora P, Subbarao P, Hooe A, Sonnappa
S. Age and height dependence of lung clearance index and functional residual capacity. Eur Respir J 2013;41:1371-1377.
Ultrasonography evaluation of a weak
diaphragm after a respiratory muscle
training
A. Longoni
Cardiac-Respiratory Rehabilitation Gym, “Paola Giancola foundation”,
Asst Lariana, Como
A. Paddeu
U.O. of Specialistic Rehabilitation 2, “Paola Giancola foundation”,
Asst Lariana, Como
e-mail: angelo.longoni@hsacomo.org
We report a case of Osas with diaphragmatic limitation and paradoxical respiration despite a normal chest radiography. This manifestation would have been missed if ultrasound was not employed.
Keywords: Diaphragm; Sonography; Paradoxical respiration; Reahabilitative program.
Background: Several clinical problems may result in diaphragm
weakness and ultrasound can be a valid dynamic procedure for it’s
kinetics evaluation respect to typically most used imaging methods
like X-Ray, Fluoroscopy and MRI that use static images, ionization
with high costs.
Diaphragm ultrasonography techniques: Diaphragmatic excursion was measured with a lower frequency curvilinear probe (microconvex range 1.5-3.5 MHZ), in anterior subcostal view. The
transducer was placed between the mid-clavicular and anterior
axillary lines, directed medially, cranially and dorsally to visualize
the posterior third of the right diaphragm, approximately 5 cm lateral to the inferior vena cava foramen. The patient was examined
lyng at 45°using the liver and spleen acoustic windows. The diaphragm is commonly seen like a 2 echogenic layers (peritoneum
and pleura) sandwiching a hypoechoic thick line. Measurement
should be made in the M-mode, from the point of maximal excursion to the baseline and paradoxical motion is considered when the
diaphragm moves away from the transducer during inspiration.
Case report: A 61 years old woman, not smoker, was hospitalized
for OSAS (AHI 25,9). Comorbidity were obesity (BMI 33,8), hypertension and diabetes mellitus 2. Ten years ago she had surgery
gynecological problem that produced a weakening of the left diaphragm. The breathe, on sitting and lying, was normal on the first
examination. Normal X-ray and spirometry (VC max 101,9%; FEV1
108,8%) but ultrasound confirmed the weakness of the diaphragm.
Maximal excursion of diaphragmatic lyne was of 2 cm to right and
< 1 cm to left with a paradoxical respiration. For her problem the
patient was trained to the use of Cpap with diurnal cycles and all
night and RT educational program. Ultrasound during Cpap showed
good diaphragmatic excursion at 6,5 cmH2O without discomfort. In
addition, the patient was introduced to a rehabilitation program of
15 days. The Fkt program consisting of one daily session of 30’ of
physiotherapy (respiratory exercises, calisthenics exercises, elastic
theraband) and two sessions of 30’ of minibike for the upper and
lower limbs.
Discussion: The patient therapy was Cpap with 6.5 cmH2O pressure with oronasal mask. At the end of rehabilitative program the
patient values were: Diaphragmatic excursion = from 2 to 6,9 cm
on the right and from 1 to 5,6 cm on the left diaphragm. WT6’=
from 275 to 435 meters; Arm band sleep quality = from 39,2% to
83,9%; Night SpO2 saturation = 94,3%
Conclusion: Using M-mode ultrasonography, it’s possible to find
diaphragmatic dysfunction in a unexpected patients. We believe
that this tecnique is inexpensive, widely available, easy to use as a
bedside exame for clinicians and RT therapist. We can asses diaphragm excursion in quiet and deep breathing in real time motion
before and after a rehabilitative program.
References
[1] Soldati G, Copetti R. Ecografia toracica. Edizioni Medico Scientifica 2012.
[2] Feletti F, Gardelli G, Mughetti M. L’ecografia toracica. Applicazioni ed imaging integrato 2010.
[3] Sarwal A, Walker FO, Cartwright MS. Neuromuscular Ultrasound
for evaluation of diaphragm. Muscle Nerve 2013;47(3):
319-329.
[4] Zanforlin A. Applicazioni cliniche e sperimentali dell’ecografia
toracica in pneumologia: la diagnostica precoce delle patologie
pleuropolmonari 2012.
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
27
[5] Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD,
McDonald C. Ultrasonographic evaluation of diaphragmatic
motion. Ultrasound Med 2001;20(6):597-604.
[6] Ferrari G, De Filippi G, Elia F, Panero F, Volpicelly G, Aprà F.
Diaphragm ultrasound as a new index of discontinuation from
mechanical ventilation. Critical Ultrasound Journal 2014;6:8.
[7] Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied
by M-mode ultrasonography: Methods, reproducibility and
normal values. Chest 2009;135(2):391-400.
[8] Block B. Guida ecografica: Atlante di diagnostica ecografica,
Verduci 2012.
[9] Soladati G. Ecografia dell’apparato respiratorio, Ed. Guidotti
2015.
[10] Diaphragmatic Motion Studied by M-Mode Us, Chest February
2009:135(2):391-400.
Neuromuscular taping as support for
respiratory rehabilitation patients with
chronic obstructive pulmonary disease
M.E. Mantovani, A. Masciotti, L. Di Vincenzo, B. Bruni, M.L. Dottorini
Respiratory Rehabilitation and Thysiopneumologic Prevention Service,
AUSL Umbria 1, Perugia, Italy
e-mail: elisamant@yahoo.it
Introduction: As part of the rehabilitation therapy to motor retraining in recent years have established new techniques such as the
application of the “neuromuscular taping” [1-3]. A recent metaanalysis confirm its efficacy in combination with traditional therapies rehabilitative [4,5].
Aim: The aim is to verify whether the application of Neuromuscular
Taping in patients with COPD, as support to the program of retraining effort, can add additional therapeutic benefits compared to exercise alone.
Methods: Study of open-ended parallel group. Study population:
n. 9 COPD patients with functional deficits of mild to moderately
severe (criteria ERS/ATS 2005) divided into two groups: the study
group A n. 5 and the control group B n. 4 patients. Group A was
applied for the duration of the entire session on the Neuromuscular
Taping intercostal muscles in compression (30% voltage) and for 5
consecutive days every other week a bandage scapular in decompression (0% voltage). Exclusion criteria: neurological, bone and
joint and cognitive deficits. Tests performed at the beginning and at
the end of the rehabilitation cycle: complete spirometry, measurement of the maximum in and expiratory mouth pressures (MIPMEP), evaluation of the degree of dyspnea (MRC), evaluation of
exercise capacity (incremental shuttle walking test ISWT and six
minute walking test 6MWT) and the quality of life (St. Georges
Questionary SGQoL, COPD Assessment Test CAT).
Rehabilitation treatment included 20 sessions of 80 minutes each,
three times a week: aerobic training circuit (35 minutes) with cycle
ergometer, treadmill and device Davenbike®; free exercises of balance and coordination in posture (35 minutes); muscle stretching
in posture with coordination exercises respiratory (10 minutes).
Statistical analysis: T Student for paired data.
Results: Group A proved statistically significant improvements
(p < 0.05) relative to the ventilatory parameters, ISWT and 6MWT
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Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
and quality of life (SGQoL that CAT). In group B, while noting improvements in respiratory parameters, ISWT and 6MWT, quality of
life (SGQoL that CAT), these did not reach statistical significance. In
both groups, MIP, MEP and MRC haven’t demonstrated statistically
significant improvements.
Conclusions: Although the number of the study population is reduced, it is striking to say, in the light of the results obtained, the
application of the Neuromuscular Taping in addition to the rehabilitation program will add additional therapeutic benefits compared to
exercise alone. Further studies are needed with larger study populations to confirm the results.
References
[1] Bellia R. Taping Kinesiologico e colonna vertebrale, manuale di
applicazione per disfunzioni della colonna vertebrale rachialgie
e disordini posturali. ED. Alea 2013.
[2] Ozmen T, Aydogmus M, Dogan H, Acar D, Zoroglu T, Willems M.
The effect of KT on muscle pain sprint performance, and flexibility in recovery from exercise. J Sport Rehabil 2015.
[3] Bravi R, Quarta E, Cohen EJ, Gottard A, Minciacchi D. A little
elastic for a better performance: KT of the motor effector modulates neural mechanisms for rhytmic movements. Frontiers in
Systems Neuroscienze, 2014.
[4] Montalvo AM, Cara EL, Myer GD. Effect of KT on pain in individualis with muscoloskeletal injuries; systematic review and
meta-analysi. Phys Sportsmed 2014.
[5] Lim EC, et al. Kinesio taping in musculoskeletal pain and disability that lasts for more than 4 weeks: is it time to peel off the
tape and throw it out with the sweat? A systematic review with
meta-analysis focused on pain and also methods of tape application. Br J Sports Med 2015.
Exercise capacity and lung impairment:
relationship between Wmax and LCI
in patients with Cystic Fibrosis
M. Mirabella
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico,
U.O.C. Nefrologia, Dialisi e Trapianto di rene
F. Carta, S. Gambazza, A. Brivio
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico,
Centro di Riferimento Regionale Fibrosi Cistica
C. Colombo
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico,
Centro di Riferimento Regionale Fibrosi Cistica; Università degli Studi
di Milano
e-mail:marina_mirabella@libero.it
Background: Cystic Fibrosis (CF) is a genetic disorder that affects
mostly the lungs, leading to a decline in lung function and poor
exercise tolerance. Exercise capacity can be evaluated in CF
through the Godfrey protocol, a continuous incremental cycle protocol to volitional fatigue, that has been used in patients with CF 6
years and older with various degree of pulmonary disease [1]. This
test has been also recommended as the second best option when
ventilatory gas analysis is not available. Lung Clereance Index (LCI)
is a measure of lung inhomogeneity derived from the Multiple
Breath Washout Test (MBWT) and it seems to be a stronger function predictor of disease progression than FEV1 alone in CF [2].
Aim: The aim of this study is to show a moderate correlation between Wmax (Godfrey’s output) and LCI.
Methods: All subjects regularly attending the CF Centre from February to July 2015 were considered eligible. They performed the
Godfrey protocol and MBWT according to clinical practice. 29 patients were necessary to determine whether the ρ coefficient differs from zero. Data are presented as mean (SD).
Results: 33 patients (18F) aged 19.3 (4.3) years were recruited:
39.4% had FEV1pred > 90%, LCI was 17. Only 39% performed a
maximal test, with a VO2 peak of 2.46 (0.71) l/min. Ninety-four
percent showed an abnormal response to exercise: 69.7% with
Wmax pred. < 93%, 33.3% with desaturation ≥ 4%, 69.7% with
inadequate cardiovascular response. Wmax (p=0.0006) and LCI
(p < 0.0001) differed among disease severity. A significant
negative correlation was detected between FEV1%pred. and LCI
(ρ=–0.7756); Wmax was significantly correlated to FEV1% pred.
(ρ=0.5988) as well as W/kg (ρ=0.6637), and both are significantly correlated to LCI.
Conclusion: Early detection of lung impairment, expressed as LCI,
when associated to an abnormal exercise response, seems to be
linked to functional capacity limitation even in those patients with
normal FEV1.
References
[1] Hebestreit H, et al. Statement on exercise testing in Cystic Fibrosis. Respiration 2015. DOI: 10.1159/000439057.
[2] Horsley A. Lung clereance index in the assessment of airways
disease. Respiratory Medicine 2009;103:793-799.
Is early mobilization feasible and safe
in patients receiving left ventricular assist
device therapy?
C. Novo, S. Pellegrina, M.E. Mazzanti, C.L. Bioletto, M. Lazzeri,
M. Cipriani
Dipartimento Cardiotoracovascolare ASST Niguarda Milano
A. Toccafondi
U.O. di Riabilitazione Cardiologica. Istituto Don Gnocchi Milano
Background: Patients with severe end-stage heart failure often
have limited tolerance to activity, loss of muscle mass and become
severely symptomatic at rest or with minimal exertion, despite
maximal medical therapy. The treatment options include the placement of a left ventricular assist device (LVAD).
Aim: To determine whether early activity is feasible and safe, whether any activity-related adverse event occurred and the patient’s
health status at discharge time from hospital in LVAD patients.
Materials and methods: A retrospective observational study was
performed from January 2014 until December 2015 on LVAD patients at cardiovascular thoracic department in Niguarda Hospital
(Milan). After LVAD implantation, the number of rehabilitation activities and the starting of mobilization and walking training have been
recorded. In addition, activity-related adverse events and the patient’s health status have been described.
Results: Twenty-eight patients [24 male; age 57 (7,4); body mass
index 26,8 (4,2); ejection fraction 22% (5)] received LVDA implantation. 71% was NYHA class III and 29% was NYHA class IV. The
post-operative recovery period after implantation was of 32 (18)
days, of which 10 (4) in the intensive care unit. Patients started
rehabilitation activity 3 (3) days after surgery, transferred to chair
10 (3,7) days after surgery and started ambulate 15 (6,9) days after surgery. 782 physiotherapy sessions have been recorded
[mean 29 (19) session/patient]. These activities included a progressive activity regimen: sitting at the edge of the bed, transfer to
a chair; recumbent or upright cycling, standing, walking and stairs
training. During exercise training 18 adverse events have been described (0.02% of all physiotherapy treatments) by 8 (29%) patients (Table 1). Such events resulted in the rehabilitation suspension until the medical therapy was adjusted.
Before the discharge, 26 patients improved their functional capacity in the activity of daily living (ADL) and in ambulation. One patient
underwent heart transplantation and one died. The patients who
received LAVD implantation in 2015 performed 6 minute walk test
(6MWT) 31±12 days after surgery, covering in average 311±57
meters.
Conclusion: Early activity is feasible and safe in LVAD patients. Exercise training has positive effects on LAVD patient’s recovery and
on their performance of daily activities already at discharge time.
References
[1] Compostella L, et al. A practical review for cardiac rehabilitation
professionals of continuous-flow left Ventricular Assist Devices.
Journal of Cardiopulmonary Rehabilitation and Prevention
2015;35:301-311.
[2] Perme CS, et al. Early mobilization of LVAD recipients. Tex
Hearth Inst Journal 2006;33:130-133.
Tabella 1
Patients
Adverse events
Activity
1
2 hypotension
1 transfer to a chair 1 upright cycling
2
1 hypotension
walking
3
7 Nonsustained ventricular tachycardia
2 transfer to a chair 2 upright cycling 2 walking
4
1 atrial fibrillo-flutter
transfer to a chair
5
1 Nonsustained ventricular tachycardia
upright cycling
6
1 hypotension
transfer to a chair
7
1 hypotension
sitting at the edge of the bed
8
4 hypotension
standing
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
29
Non-invasive ventilation outside the
intensive care unit in patients with
hypoxemic acute respiratory failure after
cardiac surgery. A randomized trial
L. Olper, S. Albini
Department of Physical Rehabilitation, San Raffaele Scientific Institute,
Università Vita-Salute San Raffaele, Milan, Italy
E. Bignami, A.L. Di Prima, S. Nascimbene, L. Cabrini
Cardiothoracic and Vascular Department, IRCCS San Raffaele Scientific
Institute, via Olgettina 60, 20132 Milan, Italy
G. Landoni, O. Alfieri
Cardiothoracic and Vascular Department, IRCCS San Raffaele Scientific
Institute, via Olgettina 60, 20132 Milan, Italy
Vita-Salute San Raffaele University, via Olgettina 58, 20132 Milan, Italy
e-mail: olper.luigi@hsr.it
Background: All randomized studies published so far demonstrating the effectiveness of non-invasive ventilation to prevent or to
treat acute respiratory failure after cardiac surgery, took place in
the Intensive Care Unit [1]. However, the commonly occurring
shortage of intensive care beds leads to evaluate if non-invasive
ventilation treatment can be conducted in non-intensive wards
while preserving its efficacy and safety.
Aim: The aim of the present study was to evaluate the effectiveness
of non-invasive ventilation therapy delivered in the cardiac surgical
ward to treat postoperative hypoxemic acute respiratory failure.
Methods: We randomly assigned 64 patients with hypoxemia admitted to the main ward after cardiac surgery to receive standard
treatment (oxygen, early mobilization, a program of breathing exercises and diuretics) or continuous positive airway pressure (oronasal mask consisting of 6 cycles of 1-3 hours each during a period of 48 hours) on top of standard treatment. Cross over to noninvasive ventilation treatment was allowed during the first 48 hours
in case of severe respiratory distress and after the first 48 hours in
case of persisting hypoxemia. All patients completed their 1-year
follow-up. The primary end point was the number of patients with
persisting acute respiratory failure, defined as a PaO2/FiO2 < 200
mmHg 48 hours after randomization. Secondary end-points included: incidence of severe acute respiratory distress; incidence of reintubation for respiratory failure; length of hospital stay. Data were
analyzed according to the intention-to-treat principle. Dichotomous
data were compared by two tailed c2 test. Continuous measurements were compared using the Mann-Whitney U test. Data are
presented as median [interquartile range].
Results: Continuous positive airway pressure use was associated
to a statistically significant reduction in the number of patients with
PaO2/FiO2 < 200 (5/33 (15%) versus 13/31 (42%), p=0.017). The
number of patients with severe acute respiratory distress was 1
(3.0%) and 4 (12%) respectively (p=0.23) with one patient in the
control group requiring tracheal re-intubation. Hospital length of
stay after randomization was not different between the control and
the treatment group (5 days [3-7] versus 4.5 days [3-6], respectively, p =0.51). One patient in the control group died at the 30
days follow up.
Conclusions: Among patients with acute respiratory failure following cardiac surgery, administration of continuous positive airway
pressure in the main ward is associated to an improved respiratory
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Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
outcome. This is the first study that was performed in the main
ward of post-surgical patients with acute respiratory failure.
References
[1] Landoni G, Zangrillo A, Cabrini L. Noninvasive ventilation after
cardiac and thoracic surgery in adult patients: a review. J Cardiothorac Vasc Anesth 2012;26:917-922.
Neuromuscular electrostimulation
of the quadriceps muscle during an
acute exacerbation of COPD
A. Panizzolo A
C.d.L in Fisioterapia, Università degli Studi dell’Insubria, Varese
D. Berra, E. Repossini
Ospedale di Busto Arsizio, ASST Valle Olona
E. Zampogna
Fondazione S. Maugeri I.R.C.C.S, Tradate
A. Spanevello
C.d.L in Fisioterapia, Università degli Studi dell’Insubria, Varese
Fondazione S. Maugeri I.R.C.C.S, Tradate
e-mail: alice.panizzolo1@gmail.com
Background: Chronic Obstructive Pulmonary Disease (COPD) is
often associated with extra-pulmonary manifestations; the dysfunction of lower-limb muscles limits physical activity and affects
quality of life (QoL). Exacerbations are events causing an additional
decrease in function.
Aims: To verify whether a short program of neuromuscular electrostimulation of the quadriceps (NMES), applied during an exacerbation, prevent the deterioration of muscular function and the consequent drops in functional capacity and QoL.
Methods: Between December 2014 and August 2015, 22 patients
– hospitalized for an exacerbation of COPD – were enrolled in the
study. 12 subjects in the control group underwent standard treatment for COPD exacerbation, while 10 patients in the study group
received, in addiction, daily electrostimulation of the quadriceps.
Both groups were then divided into two sub-groups depending on
whether a patient was dismissed or transferred to the Pulmonary
Rehabilitation department. The primary outcomes were quadriceps
muscle force (5STS Test) and QoL (SGRQ-C); the secondary outcomes were perceived dyspnoea and fatigue (modified Borg Scale).
Results: For the baseline comparison of the patients, we used either the Student’s t-test for independent samples or the MannWhitney U test. Due to the limited number of the sample, for the
comparisons across and within groups, we used the Mann-Whitney U and the Wilcoxon signed rank test, respectively. Values were
considered significant for p ≤ 0.05. The in-group comparison
showed that NMES induced an increase of the muscle strength at
the end of the acute episode in the study group, that was maintained or increased at follow-up, after two months; in the control
group, instead, the variation was smaller and it reversed in the following months. In the treated patients, NMES was associated with
a significant improvement in QoL, while in the control group we
observed an improvement in QoL only at the end of the acute episode and, after two months, the questionnaire score was unvaried.
The comparison between the two groups, instead, showed that
NMES induced a significant improvement in strength on the quadri-
ceps muscle and QoL at the end of the acute episode, and a further improvement of both parameters at follow-up. Subjects that,
at the end of the episode, followed a PR program showed an even
greater improvement in QoL compared to baseline.
Conclusions: A short program of NMES applied during an acute
exacerbation of COPD prevents the deterioration of muscular function and contributes to improve its strength. It also leads to a longterm improvement of functional capacity and, therefore, of perceived QoL.
References
[1] Spruit MA, Singh SJ, Garvey C, et al. and on behalf of the ATS/
ERS Task Force on Pulmonary Rehabilitation. An Official American Thoracic Society/European Respiratory Society Statement:
Key Concepts and Advances in Pulmonary Rehabilitation. Am J
Respir Crit Care Med 2013;188(8):e13-e64.
[2] V estbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of
Respiratory and Critical Care Medicine 2013;187(4):347-365.
[3] M
altais F, Decramer M, Casaburi R, et al. An Official American
Thoracic Society/European Respiratory Society Statement: Update on Limb Muscle Dysfunction in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2014;189(9):e15-e62.
[4] Barreiro E, Gea J. Respiratory and limb muscle dysfunction in
COPD. COPD 2014;00:1-14.
[5] Gayan-Ramirez G, Decramer M. Mechanisms of striated muscle
dysfunction during acute exacerbations of COPD. J Appl Physiol
114:1291-1299, 2013.
[6] Abdellaoui A, Préfaut C, Gouzi F, Couillard A, Coisy-Quivy M, Hugon G, Molinari N, Lafontaine T, Jonquet O, Laoudj-Chenivesse
D, et al. Skeletal muscle effects of electrostimulation after COPD
exacerbation: a pilot study. Eur Respir J 2011;38:78.
[7] V ivodtzev I, Pépin JL, Vottero G, Mayer V, Porsin B, Lévy P, Wuyam B. Improvement in quadriceps strength and dyspnea in daily
tasks after 1 month of electrical stimulation in severely deconditioned and malnourished COPD. Chest 2006;129:1540-1548.
Physical performance assessment
in subacute stroke patients: a comparison
between different tests
S. Pordon
Study University of Padua (Italy)
M. Donà, R. Mareschi, L. Nardin, S. Bargellesi
Rehabilitation Medicine, Severe Brain Injury Unit, Cà Foncello Hospital,
ULSS 9 Treviso (Italy)
e-mail: sara.pordon@hotmail.it; mdona@ulss.tv.it
Background: Stroke represents the principle cause of invalidity in
the world [1,2]. It determines physical inactivity, the assumption of
a sedentary lifestyle and a low fitness level [3,4], which are associated with inability to perform daily activities and a decrease life
quality [4-6]. Evidence-based literature shows that exercise is an
essential element for post stroke rehabilitation [3,7,8]: so we need
adequate tests to estimate the level of physical performance in
post stroke patients.
Aim: This observational study aimed at finding appropriate stress
tests to measure physical performance in sub-acute stroke patients and to create personalized reconditioning programs. We
have compared three different tests (6 Minute Walking Test, Sit to
Stand Test, cycloergometer test) to find a correlation between them
that would allow the use of simpler but equally valid ways of assessing physical performance in these patients.
Methods: The study group consists of 9 post stroke patients in
sub-acute phase. Each patient underwent: spirometry to measure
the vital capacity and the forced vital capacity, BMI calculation,
modified Borg scale training for dyspnea and muscle fatigue, Sit to
Stand Test, 6 Minute Walking Test, incremental cycloergometer test
(with leg or arm cycloergometer). Cardiac frequency, saturation,
dyspnea and muscle fatigue were monitored in each test. A significant statistical correlation between 6 Minute Walking Test vs cycloergometer test watt, and 6 Minute Walking Test vs stand-up number in Sit To Stand Test were investigated.
Results: The statistical analysis showed a significant correlation
between 6 Minute Walking Test (metres) and the maximal cycloarmergometer watts (Person’s r=0,702), and between 6 Minute
Walking Test and stand-up number (Pearson’s r=0,695).
Conclusions: It has been shown that the cycloergometer test and
Sit To Stand Test can be used as a valid alternative to the 6 Minute
Walking Test to assess the physical performance of sub-acute
stroke patients. The possibility of assessing performances with only
the cycloergometer test allows an early assessment, when the patients have not yet recuperated walking ability (essential for 6 Minute Walking Test), while Sit To Stand Test could be used to assess
patients in settings without the equipment necessary for an incremental test. Early assessment allows the creation of a retraining
program to contrast the physical decline and its negative effects on
the daily life and to increase physical function, activity, participation, life satisfaction in the patients.
References
[1] Q
uaderni del Ministero della Salute, Organizzazione dell’assistenza
all’ictus: le Stroke Unit. 2010; (2).
[2] Billinger S, et al. Physical Activity and Exercise Recommendation
for Stroke Survivors: A Statement for Healthcare Professionals
From the American Heart Association/American Stroke Association.
Journal of the American Heart Association 2014(45):2532- 2553.
[3] Billinger S, Mattlage A, Ashenden A. Aerobic exercise in subacute stroke improves cardiovascular health and physical performance. J Neurol Phys Ther 2012;36(49):159-165.
[4] Brogardh C, Lexell J. Effects of cardiorespiratory fitness and
muscle-resistance traininig after stroke 2012:4:901-907.
[5] B oyne P, Dunning K, Carl D, et al. High-Intensity Interval Training
in stroke rehabilitation. Top Stroke Rehabil 2013;20(4):317-330.
[6] Pang M, Charlesworth S, et al. Using aerobic exercise to improve health outcomes and quality of life in stroke: evidencebased exercise prescription recommendations. Cerebrovasc Dis
2013;35:7-2.
[7] Stoller O, De Bruin ED, et al. Effects of cardiovascular exercise
early after stroke: systematic review and meta-analysis. BMC
Neurology 2012;12(45):1-16.
[8] Flöel A, Werner C, Grittner U, Hesse S, et al. Physical fitness
training in subacute stroke (PHYS-STROKE) – study protocol for
a randomized controlled trial” Trials 2014(15)45:1-12.
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
31
The delivery of a self-management
manual for COPD by practice nurses
in primary care: does it improve disease
knowledge?
Bacterial contamination of nebulizers
after aerosol-therapy in cystic fibrosis
patients: evaluation of the steam
disinfection efficacy
V. Rossi, L. Houchen-Wolloff, S. Schreder
Centre for Exercise and Rehabilitation Science, Leicester Respiratory
Biomedical Research Unit, University Hospitals Leicester NHS Trust,
Leicester, LE3 9QP, UK
S.J. Singh
Centre for Exercise and Rehabilitation Science, Leicester Respiratory
Biomedical Research Unit, University Hospitals Leicester NHS Trust,
Leicester, LE3 9QP, UK
School of Sport, Exercise and Health Sciences Loughborough
University, LE11 3TU, UK
e-mail: veronica.rossi@uhl-tr.nhs.uk
M. Rossitto, V. Tuccio Guarna Assanti
Fellowship, Children’s Hospital and Research Institute Bambino Gesù,
Rome
P. Leone
Rehabilitation Unit, Children’s Hospital and Research Institute Bambino
Gesù, Rome
F. Felicetti
Cystic Fibrosis Unit, Children’s Hospital and Research Institute Bambino
Gesù, Rome
I. Piermarini
Cystic Fibrosis Unit, Children’s Hospital and Research Institute Bambino
Gesù, Rome
G. Ricciotti, E.V. Fiscarelli
Cystic Fibrosis Microbiology, Children’s Hospital and Research Institute
Bambino Gesù, Rome
Background: Self-management plays a crucial role in the management of chronic obstructive pulmonary disease (COPD). The “Selfmanagement Programme of Activity, Coping and Education for
Chronic Obstructive Pulmonary Disease” (or “SPACE for COPD”)
manual is known to be effective when delivered by researchers [1].
However there is a need to examine this approach in primary care
when delivered by practice nurses.
Aim: To evaluate the effectiveness of the SPACE for COPD manual
when delivered in primary care by practice nurses.
Methods: 26 patients with mild to severe COPD in primary care
were recruited from 2 sites in the UK (Northampton and Leicester).
They received a self-management manual following a face-to-face
consultation and telephone follow-up support by practice nurses
for 6 weeks. The primary outcome was disease knowledge using
the Bristol COPD Knowledge Questionnaire (BCKQ). Secondary outcomes included: Hospital Anxiety and Depression Scale (HADS),
COPD Assessment Test (CAT) and the Stanford Self efficacy questionnaire. Outcome measures were recorded at baseline, 6 weeks
and 6 months.
Results: A total of 26 patients (13 males: mean [SD] age 69 [±9.5]
years, FEV1% 1.99 [±0.8], BMI 27,4 [±5,4]; pack/years 25.2
[±16.9], MRC 3 [±1], HADS Depression 6.4 [±4.1], HADS Anxiety
6.3 [±4.1]), showed at 6 weeks a statistically significant improvement for the BCKQ Total Score [mean change 7.93 (95% confidence interval 3.19-12.67, p=0.003)] and HADS Depression
[mean change of –1.36 (95% confidence interval –2.22 to –0.49,
p=0.005)]. The BCKQ domains of dyspnea, phlegm, vaccination
and exercise showed a statistical change at 6 weeks (p<0.005).
There were no improvements for the other outcome measures at 6
weeks. There were no significant changes in the disease knowledge and depression at 6 months. There was no difference between the 2 sites.
Conclusion: This brief intervention seems to improve disease
knowledge and decrease depression levels in this population at 6
weeks. These changes were not sustained at 6 months. It may be
that for long-term improvements, a longer or more intense programme is required.
References
[1] Mitchell K, Johnson-Warrington V, Apps L, et al. A self-management programme for COPD: a randomised controlled trial. European Respiratory Journal 2014. DOI: 10.1183/09031936.
00047814.
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Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
Background: A key factor for preventing and controlling lung infections in cystic fibrosis (CF) is the use of effective methods for disinfecting the equipment used by the patient for home inhalation
therapy. IPC Guidelines of CFF recommend several methods. As
they are time-consuming for the patients and their families, home
steam disinfection is being widely used, having the advantage to
be compatible with the patients’ daily activities. However, studies
on its efficacy are still scarce.
Aims are to:
> describe the rate of bacterial contamination of an aerosol equipment after 1 inhalation session in CF patients with chronic pulmonary colonization;
> highlight the ampoule contamination rate after cleaning and disinfecting by using NUK sterilizer;
> define the correlation between the microorganisms that colonize
the patients’ lungs and microorganisms isolated in the ampoule.
Methods: Eighteen patients, followed at CF Center of Pediatric
Hospital Bambino Gesù, were enrolled. The patients, selected according to their microbiological status, underwent two consecutive
sessions of therapy with aerosolized saline solution (eFlow-rapid®,
Pari). The two ampoules of each patient, one of which washed with
water and detergent and disinfected through NUK, was sent to the
microbiology laboratory for investigations. Each ampoule, disassembled into mouthpiece, membranes, nebulizer cup has been
used in a culture test according to the standard procedures.
Results: Eighteen couples of ampoules were analyzed. All ampoules were contaminated (100%) with no relation among the bacterial species colonizing the lungs and the contaminating microorganisms. The 18 non-treated ampoules showed a growth with high
loads (cfu:>=106/mL) of microorganisms constituting the microflora of the oral cavity and thermophilic bacilli at environmental diffusion [viridans streptococci (18); coagulase-negative staphylococci (28) and Bacillus/Brevibacillus spp (35)]; 4 and 8 ampoules
were contaminated by coagulase-positive staphylococci and Enterococcus spp, respectively. The 18 ampoules subject to cleansing
and disinfection by NUK presented contamination by coagulasenegative staphylococci (8) and Bacillus/Brevibacillus spp (36); the
latter were also isolated from water samples used for rinsing the
ampoule and the vaporizer chamber inner surfaces.
Conclusions: After the first session of inhalation therapy, the ampoules result contaminated by commensal flora of the skin and oral
cavity, as well as by environmental thermophilic microorganisms,
with no correlation with the patients’ microbiological status. The
steam disinfection is bactericidal for almost all the contaminating
bacterial species with the exception of spore-forming organisms of
Bacillus/Brevibacillus that are ubiquitous in the environment and
thermotolerant for temperatures higher than 60° C.
References
[1] Vassal S, Taamma R, Marty N, Sardet A, d’Athis P, Bremont F, et
al. Microbiologic contamination study of nebulizers after aerosol
therapy in patients with cystic fibrosis. American Journal of Infection Control 2000;28(5):347-351.
[2] Conway S, Balfour-Lynn IM, De Rijcke K, Drevinek P, Foweraker,
J, Havermans, et al. European Cystic Fibrosis Society Standards
of Care: framework for the cystic fibrosis centre. Journal of
Cystic Fibrosis 2014;13:S3-S22.
[3] Saiman L, Siegel JD, LiPuma JJ, Brown RF, Bryson EA, Chambers MJ, et al. Infection prevention and control guideline for
cystic fibrosis: 2013 update. Infection Control and Hospital Epidemiology 2014;35(S1):S1-S67.
Cardiac and pulmonary rehabilitation:
results of an integrated training program
C. Simonelli, F. Rivadossi, S. Scalvini
Unità di Cardiologia Riabilitativa, Fondazione S.Maugeri IRCCS,
Lumezzane (BS)
M. Paneroni, M. Saleri, D. Trainini, M. Vitacca
Unità di Pneumologia Riabilitativa, Fondazione S.Maugeri IRCCS,
Lumezzane (BS)
e-mail: carla.simonelli@fsm.it
Background: Dyspnea and effort intolerance are typical symptoms
in patients with cardiac and pulmonary chronic diseases and exercise training is a key component of their management. It’s unknown if the administration of the same training protocol to cardiac
and respiratory patients will give similar results. After setting up a
problem-oriented prescriptive protocol of exercise training, we analyzed outcomes with the aim to find similarity and differences between cardiac (C) and respiratory (R) patients’ responses.
Methods: All consecutive outpatients referred to Cardiac and Pulmonary Rehabilitation Units completed 20 sessions (2-3/week,
lasting 2 hours each). At admission, each patients was assessed
in: 1) functional capacity by 6-minute walk test (6MWT), 2) peripheral muscle strength by dynamometer, 3) balance by Risk of Falls
Index, 4) inspiratory and expiratory muscle strength (MIP, MEP), 5)
level of physical activity by accelerometer. Exercise training was set
up by the physiotherapist, following a guided protocol based on a
prescriptive algorithm defined by the team. The training protocol
established the administration of training on the basis of the assessed area that had resulted impaired. According to the algorithm,
were administered: aerobic cycling or treadmill training (constantload or interval training), muscle strengthening, balance exercises,
respiratory muscle strengthening, and domiciliary walking with
pedometer.
Results: Between February and December 2015, 161 patients
[age 67.43 (10.02) years, BMI 27.05 (4.85), male 65,43%] completed the training program, of which 71 were cardiac patients (11
chronic heart failure, 29 after myocardial revascularization procedures, 21 coronary artery disease, 10 after hearth valve surgery),
and 90 were respiratory patients (63 chronic obstructive pulmonary disease, 17 chronic asthma). No major adverse events occurred. At admission, BMI [C 28.48(4.93) vs P 25.90 (4.5),
p=0.006] and functional capacity [C 466 (93) vs 433(102) meters,
p=0.0325] were different between groups. The training program
produced a significant improvement of functional capacity
[+30,64(68,56) meters, p<0,0001], quadriceps muscle strength
[+2,55(8,28) kg, p<0,0001], biceps muscle strength [+2,24(4,80)
kg, p<0,0001], inspiratory and expiratory muscle strength [+5,69
(14,38) and +7,40 (24,47) cmH2O, p<0,0001, respectively], and
daily steps [+120 (2817) steps, p=0,01]. Balance did not improve
significantly. C and P patients’ responses were not significantly different, except for physical activity that improved significantly more
in C than in P patients [C +1039 (2644) vs P –546 (2769) daily
steps, p=0.01].
Conclusions: Our training program produced similar functional improvements in cardiac and pulmonary patients, except for physical
activity. This suggests that a common and integrated training protocol could be feasible. Further studies to test impact on healthcare
organization and cost-effectiveness are needed.
Implementation of a guided protocol
to prescribe exercise training in
cardiopulmonary rehabilitation
C. Simonelli, F. Rivadossi, S. Scalvini
Unità di Cardiologia Riabilitativa, Fondazione S.Maugeri IRCCS,
Lumezzane (BS)
M. Paneroni, M. Saleri, D. Trainini, M. Vitacca
Unità di Pneumologia Riabilitativa, Fondazione S.Maugeri IRCCS,
Lumezzane (BS)
e-mail: carla.simonelli@fsm.it
Background: Exercise training is a key component of cardiac and
pulmonary chronic diseases management. The possibility to administer the same training protocol is understudied, but it may improve healthcare organization. Aims of this study were: 1) to test
the feasibility of a physiotherapist-driven problem-oriented protocol
for the prescription of exercise training; and 2) to compare the typology of delivered performance with those administered in the 10
months before protocol implementation.
Methods: All consecutive outpatients referred to Cardiac and Pulmonary Rehabilitation Units completed 20 sessions (2-3/week,
lasting 2 hours each). At admission, each patients was evaluated
in: 1) functional capacity by 6-minute walk test (6MWT), 2) peripheral muscle strength by dynamometer, 3) balance by Risk of Falls
Index, 4) inspiratory and expiratory muscle strength (MIP, MEP), 5)
level of physical activity by accelerometer. Exercise training was set
up by the physiotherapist, following a guided protocol based on a
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
33
prescriptive algorithm. The training protocol established the administration of training on the basis of the assessed area that had resulted impaired. According to the algorithm, were administered:
aerobic cycling or treadmill training (constant-load or interval training), muscle strengthening, balance exercises, respiratory muscle
strengthening, and domiciliary walking with pedometer.
Results: Between February and December 2015, 161 patients
[age 67.43 (10.02) years, BMI 27.05 (4.85), male 65,43%] completed the training program, of which 71 were cardiac patients (11
chronic heart failure, 29 after myocardial revascularization procedures, 21 coronary artery disease, 10 after hearth valve surgery),
and 90 were respiratory patients (63 chronic obstructive pulmonary
disease, 17 chronic asthma). 3780 sessions of rehabilitation were
administered. No major adverse events occurred. Comparisons of
prescription typology with the previous 10 months (From May
2014 to January 2015, 207 admitted patients, 4140 sessions) revealed significant changes: constant-load cycling training was less
prescribed (from 87% to 53%, p<0,05), while interval training increased (from 0 to 36%, p<0,05), and treadmill walking didn’t
change significantly; non-specific muscle strengthening was less
prescribed (from 100% to 23%, p<0,05), while specific muscle
training was prescribed significantly more than before (leg training
+32%, arm training +5%, combined arm and leg training +10%,
p<0,05), and also balance training (+30%, p<0,05). Furthermore,
7956 domiciliary sessions were prescribed. The training program
produced a significant improvement of all outcomes [6MWT +7.54
(16.78)%, quadriceps strength +14.26 (40.88)%, biceps strength
+15.26 (31.96)%, MIP +6.66 (22.16)%, MEP +9.25 (26.74)%,
daily steps +17.66 (76.98)%], except for balance.
Conclusions: The protocol proved to be feasible, safe and able to
improve tailoring of the rehabilitative program.
Preliminary data and feasibility of an
early pulmonary rehabilitation program
in surgically treated lung cancer patients
P.F. Sobral Rebelo, C. Mainini, R. Bardelli, B. Kopliku, C. Tedeschi,
S. Fugazzaro
Unit of Physical and Rehabilitation Medicine, Istituto di Ricerca e Cura
a Carattere Scientifico, Arcispedale Santa Maria Nuova, Reggio Emilia
S. Tenconi, C. Rapicetta
Unit of Thoracic Surgery, Istituto di Ricerca e Cura a Carattere Scientifico,
Arcispedale Santa Maria Nuova, Reggio Emilia
R. Piro
Unit of Pneumology, Istituto di Ricerca e Cura a Carattere Scientifico,
Arcispedale Santa Maria Nuova, Reggio Emilia
S. Costi
Unit of Physical and Rehabilitation Medicine, Istituto di Ricerca e Cura
a Carattere Scientifico, Arcispedale Santa Maria Nuova, Reggio Emilia
Department of Biomedical, Metabolic and Neural Sciences, University
of Modena and Reggio Emilia, Italy
e-mail: roberta.bardelli@asmn.re.it
Background: Non-Small Cell Lung Cancer is one of the most frequent cancers. The election treatment for Non-Small Cell Lung
Cancer is lung resection by increasing survival, nevertheless, it has
a relevant impact in patients quality of life and functional conditioning. Therefore there is a growing interest in investigating the po34
Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
tential effects of a pulmonary rehabilitation programme, either before and after surgery, aiming to improve patients’ physical and
mental condition.
Aim: Assess the immediate and long-term effects of a perioperative pulmonary rehabilitation programme for lung cancer patients
surgically treated.
Methods: Single blinded randomised controlled trial. Participants:
suspected or diagnosed primary lung cancer (stage Ia-IIb) eligible
for surgical treatment. Standard care: one therapeutic educational
session the day before surgery and standard inpatient pulmonary
rehabilitation after surgery. Intervention group: standard inpatient
pulmonary rehabilitation after surgery; preoperative pulmonary rehabilitation (14 sessions – 6 outpatients and 8 home based) and
postoperative pulmonary rehabilitation (39 session – 15 outpatients and 24 home based), both based on aerobic, resistance and
respiratory training, including an educational component in the first
preoperative session and scar massage and gymnastic group in
the postoperative programme. Outcomes: Six-Minutes Walk Test,
Pulmonary Function Tests, Short Form-12 assessment questionnaire, Hospital Anxiety and Depression Scale, Numeric Rating
Scale, length of hospital stay and perioperative complications. Assessments: T0 – baseline; T1 – one day before surgery; T2 – one
month after surgery; T3 – six months after surgery.
Results: To date we enrolled 24 patients, 13 in the intervention group
and 11 in the control group. Mean age: 68,3; 8 female, 16 male. We
observed a good compliance in the preoperative programme (96.6%
outpatients and 83.7% home based). We will present updated data
at T0, T1 and T2 and the corresponding comparisons.
Conclusions: Preliminary data confirm the feasibility of the treatment plan and patients’ compliance to protocol.
References
[1] Brocki BC, Andreasen J, Nielsen LR, Nekrasas V, Gorst-Rasmussen A, Westerdahl E. Short and long-term effects of supervised versus unsupervised exercise training on health-related
quality of life and functional outcomes following lung cancer
surgery – a randomized controlled trial. Lung Cancer 2014;
83(1):102-108.
[2] Crandall K, Maguire R, Campbell A, Kearney N. Exercise intervention for patients surgically treated for Non-Small Cell Lung
Cancer (NSCLC): a systematic review. Surg Oncol 2014;23(1):
17-30.
Video call educational program
in CF adolescents
F. Timelli, A. Fogazzi, A. Vezzoli
FT Centro Regionale di Supporto per la Fibrosi Cistica di Brescia,
Ospedale dei Bambini, Brescia
A. Zorzi, V. Tradati
Psicologa Centro Regionale di Supporto per la Fibrosi Cistica di Brescia,
Ospedale dei Bambini, Brescia
S. Timpano, R. Padoan
Dirigente medico Centro Regionale di Supporto per la Fibrosi Cistica
di Brescia, Ospedale dei Bambini, Brescia
Background: Airway clearance technique (ACT) and inhalation
therapy (IT) are essential in the management of cystic fibrosis (CF)
lung disease, however their benefits depend greatly on patients’
adherence. Lack of adherence to ACT is proven to occur more than
50% of the times, being common in adolescents.
Aim: Aim of our study was to evaluate if a video call educational
program is able to improve a) knowledge of the sequence of administration of inhaled drugs; b) ability to prepare and perform the
session of IT and ACT; c) ability to clean the devices for physiotherapy and IT in a population of CF adolescents.
Methods: Prospective 6mo interventional, single-arm open-label
study. Inclusion criteria: Diagnosis of CF, aged 12-18ys, ability to
perform spirometry, informed consent. Eleven patient were enrolled
(5 M). At start, all patients filled a Q1 (available technologies and
informed consent) and a Q2 questionnaires (personal expectations). At the end, they completed a Q3 satisfaction questionnaire.
At start and end, spirometry and 6 minute walking test were performed. A physiotherapist monitored patients home-program via
video call 2 times/week for 45’ for 6 months. At start, after 3 and 6
months, a form was filled for each patient, evaluating session’s independence and awareness (a, b, c). Qualitative and quantitative
evaluation of the variables considered in Q2 and Q3 and in forms
filled during video calls were performed. To evaluate statistical significance, the chi-square test was used.
Results: 6/11 patients were pleased to participate, considering
this study an opportunity to maintain frequent contact with physiotherapists (36.6%) and a way to monitor their home-program
(45.5%). 9/11 adhered spontaneously. Only 1 patient was forced.
All patients consider ACT very important to maintain their health.
Their main expectations were to improve technique (54.5%), receive helpful advice (54.5%), show their independence (18.2%).
At end a greater awareness and self-government in ACT and IT
was evident. Changes in their knowledge and ability (a, b) were
statistically significant (p<0,0001). No improvement in ability of
devices cleaning/disinfection appeared. Q3 showed that ACT was
considered important although the efforts it requires. 9/11 were
pleased to participate as they have received helpful advice maintaining a contact with physiotherapists (55%). 7/11 felt emotionally
supported.
Conclusion: Video call could be a helpful therapeutic tool in a CF
scenario. In the short period ACT monitoring and educational interventions, performed by video call, improved patient’s ability and
knowledge, promoting patient’s independence and awareness.
Grant GILEAD
References
[1] Savage E, Beirne PV, Ni Chroinin M, Duff A, Fitzgerald T, Farrell
D. Self-management education for cystic fibrosis. Cochrane
Database Syst Rev. 2011 Jul 6;(7):CD007641.
[2] O’Donohoe R, Fullen BM. Adherence of subjects with cystic fibrosis to their home program: a systematic review. Respir Care.
2014 Nov;59(11):1731-1746.
[3] Homnick DN. Making airway clearance successful. Paediatr
Respir Rev. 2007 Mar;8(1):40-45.
Effects of a comprehensive multimodal
intervention program in patients with
obstructive sleep apnea syndrome
O. Garmendia, J.D. Martí, C. Embid, J.M. Montserrat
Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona,
Barcelona, Spain
R. Torres-Castro
Servicio de Neumología, Unidad del Sueño, Hospital Clínic de Barcelona,
Barcelona, Spain
Departamento de Kinesiología, Facultad de Medicina, Universidad
de Chile, Chile
J. Vilaró
FCS Blanquerna, Grup de Recerca en Salut, Activitat Física i Esport
(SAFE), Universitat Ramon Llull, Barcelona, Spain
B. Roman Andrioni
Servicio de Endocrinología, Hospital Clínic de Barcelona, Barcelona,
España
J. Rodriguez
Programa de Bioestadística, Escuela de Salud Pública, Universidad
de Chile, Chile
Background: Obstructive sleep apnea syndrome (OSA) is characterized by repetitive obstruction of the upper airway during sleep,
and is associated with a wide range of health consequences such
as cognitive impairment, metabolic and cardiovascular diseases.
Physical activity is associated with a decrease in the prevalence of
OSA, improved sleep efficiency and the Epworth Sleepiness Scale
and recent evidence has shown that oropharyngeal exercises may
be useful in the treatment of OSA, reducing the snoring, subjective
sleepiness, AHI and improving the quality of life.
Aim: To investigate, in patients with moderate to severe OSA, the
effects of a combined general physical training program, oropharyngeal exercises and weight loss in the AHI.
Methods: We conducted a randomized clinical trial (clinicaltrials.
org: NCT02482480) and recruited participants in the Hospital Clinic, Barcelona, Spain. Patients were screened daily to identify adults
(≥40 and ≤85 years of age) with recently diagnosed moderate or
severe OSA (AHI ≥15 events/hour) and candidates for CPAP. We
excluded patients with body mass index (BMI) >40 kg/m, invaliding
somnolence affecting patients’ physical or daily activity and muscle-skeleton alteration impairing exercise practice. Patients were
evaluated by polysomnography and respiratory polygraphy, anthropometrical measurements, six minutes walking test (6MWT) and
symptoms and quality of life questionnaires. Participants in the intervention group followed a combined program based in general
physical activity, oropharyngeal exercises and diet control. Physical
activity consisted in 30 minutes walking along urban park tracks
for 8 weeks with 3 sessions/week (24 sessions in total). Participants in the control group received general recommendations regarding physical activity, diet and sleep hygiene.
Results: A total of 33 patients were screened, of whom 27 were
enrolled and randomized. The mean age was 63.7±12.2 years.
The mean of AHI index was 33.9±14.1 events/hour. Patients in the
intervention group presented a decrease before-after intervention
in body weight (86.9±16.4 vs 84.9±15.6; p=0.001), BMI (31.3±
4.9 vs 30.6±4.7; p=0.001), hip circumference (109.4±10.4 vs
108.1±9.7; p=0.022), and distance walked during 6MWT
(548.2±83.9 vs 567.1±85.3; p=0.013). No significant changes
Gennaio-Aprile 2016 • Numero 1 Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria
35
were observed in the AHI index. In subjects with less than 60 years
old (n=6) AHI pre and post intervention decreased from 34.5±16.8
to 20.5±11.8 events/h (p=0.016), while in subjects older than 60
years (n=8) AHI increased from 30.4±9.1 to 38.5±13.9 events/h
(p=0.013).
Conclusions: A comprehensive community combined global and
oropharyngeal exercise and diet therapy program reduced body
weight and increased walking distance capacity of patients with
moderate to severe OSA. In patients under 60 years old, a significant decrease in AHI was achieved.
Transdiaphragmatic phrenic nerve pacing:
a case report
P. Subert, M. Giacomini, F. Curto
Department of Emergency, Niguarda Ca’ Granda Hospital, Milan
G. Stagni
Department of Spinal Unit, Niguarda Ca’ Granda Hospital, Milan
Introduction: Children with high cervical spinal cord injury (SCI)
suffer from respiratory muscle paralysis resulting in the need for
long-term mechanical ventilation tracheostomy [1,2]. While effective in maintaining life support, mechanical positive pressure ventilation is associated with significant negative attributes and adds to
the complexity of care of the individual [3,4]. In order to restore a
para-physiological ventilation, diaphragmatic pacing system (DPS)
through electrical stimulation of the intact phrenic nerve has been
proposed [5-7]. In selected patients, electrodes are placed on the
abdominal side of the diaphragm via laparoscopy which when they
stimulated lead to muscle contraction and ventilation [8,9]. This
technique is less invasive and risky than phrenic nerve stimulation
[10]. In literature very few case reports have been described using
DPS in children with high cervical SCI [1-3].
Aim: This case report aims to show the feasibility of DPS in a two
years old child.
Materials: F.A, a two years old child, suffered a traumatic cervical
SCI (C 2 ASIA A) in November 18th 2014 that caused tetraplegia
and respiratory muscle failure. In December 12th the child was
surgically tracheostomized (Bivona Pediatric Flextend TSS Cuff, ID
4,5, OD 6,7, L 48 mm) and he required continuous mechanical
ventilation. The patient was unable to be disconnected from the
ventilation with no misurable vital capacity. After one year from the
trauma, 4 percutaneous intramuscular diaphragmatic electrodes
were placed within the costal portion of each hemidiaphragm.
Methods: Immediately after the implantation, stimulation trials
have been provided both in supine and sitting position with deflated tracheal cannula and heat and moisture exchanger (HME). Cardiac frequency (FC), oxygen saturation (SpO2) and current volume
(VC) were monitored at the beginning, after two minutes and every
five minutes. Each trial stopped if FC >160 bm or SpO2 <95%, or
for patient discomfort. No stimulation with the speaking valve occurred for acute respiratory distress. Among the stimuli there was
an interval of at least one hour.
Results: The first stimuli lasted between 10’-12’ and at the third
day the child was able to maintain the DPS for more than two
hours. After three months from the implantation, the DPS is provided for 11 hours at night and for 6 hours during the day but not
36
Rivista Italiana di Fisioterapia e Riabilitazione Respiratoria Gennaio-Aprile 2016 • Numero 1
consecutively. The diurnal stimulation is indeed limited by the fact
that the young child is unable to speak with the DPS and therefore
mechanical ventilation is still necessary for fonation. Further investigations are needed to overcome this limit. No other complications, such as infections or desaturations have been reported.
Conclusions: This case illustrates that the DPS can be safely implanted in children with high SCI, allowing them the benefits of
natural negative pressure breathing with their own diaphragms.
DPS appears to be effective and offers substantial benefits compared to entire positive mechanical ventilation with also significant
advantages in quality life. The greatest advantage is the increased
mobility that means the possibility for the parents to hold the baby
without obstacles caused by mechanical ventilator.
References
[1] Onders RM. First reported experience with intramuscular diaphragm pacing in replacing positive pressure mechanical ventilators in children. Journal of Pediatric Surgery 2011;46(1):
72-76.
[2] Onders RP. Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence. The
Journal of Spinal cord Medicine.
[3] Tibballs JA. Diaphragmatic pacing: an alternative to long-term
ventilation. Anaesth Intensive Care 1991;19:597-601.
[4] Garara B. Intramuscular diaphragmatic stimulation for patients
with traumatic high cervical injuries and ventilator dependent
respiratory failure: A systematic review of safety and effectiveness. Injury 2016.
[5] Glenn WW. Diaphragmatic pacing by electrical stimulation of
the phrenic nerve. Neurosurgery 1985;17:974-984.
[6] Tedde ML. Diaphragmatic pacing stimulation in spinal cord
injury: anesthetic and perioperative management. Clinics
2012;67(11):1265-1269.
[7] Posluszny JA. Multicenter review of diaphragm pacing in spinal cord injury: Successful not only in weaning from ventilators but also in bridging to independent. Journal Of Trauma
and Acute Care Surgery 2014;76(2):303-310.
[8] Di Marco AF. Inspiratory muscle pacing in spinal cord injury:
Case report and clinical commentary. J Spinal cord Med
2006;29(2):95-108.
[9] Di Marco A. Phrenic nerve pacing via intramuscular diaphragm
electrodes in tetraplegic subjects. Chest 2005;127(2):671-678.
[10] Di Marco A. Phrenic nerve stimulation in patients with spinal
cord injury. Respiratory Physiology & Neurobiology 2009;169:
200-209.
Skeletal muscles’ strength and exercise
capacity in patients with Cystic Fibrosis
B. Tavola
Università degli Studi di Milano, CdL Fisioterapia
A.M. Bulfamante, F. Carta, S. Gambazza, A. Brivio, C. Colombo
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico,
Centro di Riferimento Regionale Fibrosi Cistica
e-mail: barbara.tavola@studenti.unimi.it
Background: Cystic Fibrosis (CF) is a multisystem disease that
leads to a progressive loss of muscles’ strength and endurance.
However high levels of exercise capacity are associated with a
slower progression of lung disease, and are associated with increased survival [1], higher bone density and muscles’ strength [2].
Aim: To show a moderate correlation (rho=0.5) between exercise
capacity and skeletal muscles’ strength (quadriceps femoris) in patients with CF.
Materials and methods: Patients with CF, aged between 16 and
30 years old, regularly followed-up at the CF centre of Milan, performed spirometry (FEV1% pred), incremental exercise test (Godfrey protocol), the 1RM test for the evaluation of skeletal muscles’
strength and underwent nutritional evaluation (Body Max Index –
BMI – triceps, biceps, suprailiac, subscapular skinfolds) during
February-September 2015. All patients were clinically stable without contraindications to test procedures. Data are presented as
mean (standard deviation).
Results: 10 patients were recruited (5F): mean age was 21±3.4
years, mean BMI was 19.73±2.86 kg/m2, and mean FEV1 of
86.1±39.6% predicted; 2 patients have CF-related diabetes and 9
show pancreas insufficiency. Quadriceps femoris’ strength and exercise capacity (Wmax) showed a very strong correlation (rho =
0.8868, p=0.0006) as well as biceps brachii’s strength and Wmax,
positively correlated (rho=0.7012, p=0.0239). 50% of patients
performed a maximal test and only 10% had a normal exercise
response; Wmax reached 146±65.35 Watt, corresponding to 81%
of predicted. 1RM of the quadriceps femoris was 97.78±151.89
kg, while the one of biceps brachii was 9.10±4.24 kg. The nutritional evaluation revealed that patients who performed a maximal
test (Wmax > 93% Wmax pred.) have lower lean body mass and
higher BMI.
Conclusions: Evaluation of exercise capacity gives useful information for the care of patients with CF, especially if combined with
nutritional evaluation. However we need to further verify the correlation between exercise capacity, nutritional status and muscle
strength, taking into considerations other muscle groups and a
larger sample.
References
[1] Nixon PA, Orenstein DM, Kelsey FS, Doershuk CF. The prognostic value of exercise testing in patient with cystic fibrosis. N Engl
J Med 1992;327:1785-1788.
[2] Paranjape SM, Barnes LA, Carson KA, von Berg K, Loosen H,
Mogayzel PJ. Exercise improves lung function and habitual activity in children with cystic fibrosis. J Cyst Fibros 2012;11(1):
18-23.
Assessment of airways protection:
Voluntary and reflex cough in ALS patients
C. Zanetti, C. Enrichi, I. Koch, S. Rossi, F. Piccione, I. Battel
I.R.C.C.S. Fondazione Ospedale San Camillo, Rehabilitation Institute,
Lido di Venezia (VE)
e-mail: cristiano.zanetti@ospedalesancamillo.net
Background: The present study investigates the presence and
strength of reflex and voluntary cough in patients with Amyotrophic
Lateral Sclerosis (ALS). The assessment of cough provides information regarding the ability not only to expel food and/or liquids
that could be inhaled but also to maintain airway [1] clearance.
This assessment is particularly fundamental in patients with ALS
who have a deficit of the [2,3] respiratory muscles and inability to
generate inspiratory and expiratory flow.
Aims: The first goal of this study is to provide preliminary data of
the PCF of voluntary and reflex cough in ALS patients and to compare them with a control group of healthy subjects.
Methods: It has been recruited 6 healthy participants (2 female-4
male; age mean 58±19.3); 16 patients (9 female-8 male; age
mean 61.9±15.3) with a diagnosis of ALS. Exclusion criteria were
bulbar onset and presence of tracheostomy. Subjects were assessed by spirometer as follow: a) FVC; b) Vt; c) MEP; d) MIP; e)
Voluntary and reflex PCF [2,3]. Cough Reflex would be trigged by
the inhalation of 0.4M of citric acid solution using the ultrasonic
nebulizer connected with the spirometer via a bidirectional valve
[4]. To our knowledge PCF of reflex cough has not already been
investigated and this study was registered to clinicaltrails.gov.
Results: These preliminary data have shown that there is significant discrepancy between the PCF of Voluntary and Reflex Cough
in the group of ALS patients and also in health group (T-test p-value < 0.001). In ALS patient PCF of voluntary cough ranges from 86
to 452 l/min mean 231±107 and PCF of reflex cough from 0 to
261 l/min, mean 124±80. In healthy subject PCF of voluntary
cough ranges from 280 to 495 l/min mean 372±76 and PCF of
reflex cough from 72 to 265 l/min mean 151±56. There is moderate correlation (r=0.4; p < 0.05) between the PCF of voluntary and
reflex cough in both groups and also a signficative correlation between PCF of reflex cough and FVC (r=0.612 p-value < 0.05) in
ALS group.
Conclusions: The results show the preliminary data regarding the
assessment of reflex and voluntary PCF. This study is ongoing and
it is part of a broad study which aims to verify if the voluntary and
reflex PCF could be a prognostic value of tracheostomy intervention in order to limit the risk of emergency event.
References
[1] Miller RG1, Jackson CE, Kasarskis EJ, England JD, Forshew D,
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