Inspiratory muscle training in patients with cystic fibrosis

A Dutch paediatric palliative care guideline: a systematic review and evidence-based recommendations for symptom treatment

BACKGROUND

Children with life-threatening and life-limiting conditions can experience high levels of suffering due to multiple distressing symptoms that result in poor quality of life and increase risk of long-term distress in their family members. High quality symptom treatment is needed for all these children and their families, even more so at the end-of-life. In this paper, we provide evidence-based recommendations for symptom treatment in paediatric palliative patients to optimize care.

METHODS

A multidisciplinary panel of 56 experts in paediatric palliative care and nine (bereaved) parents was established to develop recommendations on symptom treatment in paediatric palliative care including anxiety and depression, delirium, dyspnoea, haematological symptoms, coughing, skin complaints, nausea and vomiting, neurological symptoms, pain, death rattle, fatigue, paediatric palliative sedation and forgoing hydration and nutrition. Recommendations were based on evidence from a systematic literature search, additional literature sources (such as guidelines), clinical expertise, and patient and family values. We used the GRADE methodology for appraisal of evidence. Parents were included in the guideline panel to ensure the representation of patient and family values.

RESULTS

We included a total of 18 studies that reported on the effects of specific (non) pharmacological interventions to treat symptoms in paediatric palliative care. A few of these interventions showed significant improvement in symptom relief. This evidence could only (partly) answer eight out of 27 clinical questions. We included 29 guidelines and two textbooks as additional literature to deal with lack of evidence. In total, we formulated 221 recommendations on symptom treatment in paediatric palliative care based on evidence, additional literature, clinical expertise, and patient and family values.

CONCLUSION

Even though available evidence on symptom-related paediatric palliative care interventions has increased, there still is a paucity of evidence in paediatric palliative care. We urge for international multidisciplinary multi-institutional collaboration to perform high-quality research and contribute to the optimization of symptom relief in palliative care for all children worldwide.

Palliative care for children: methodology for the development of a national clinical practice guideline

BACKGROUND

Provision of paediatric palliative care for children with life-threatening or life-limiting conditions and their families is often complex. Guidelines can support professionals to deliver high quality care. Stakeholders expressed the need to update the first Dutch paediatric palliative care guideline with new scientific literature and new topics. This paper provides an overview of the methodology that is used for the revision of the Dutch paediatric palliative care guideline and a brief presentation of the identified evidence.

METHODS

The revised paediatric palliative care guideline was developed with a multidisciplinary guideline panel of 72 experts in paediatric palliative care and nine (bereaved) parents of children with life-threatening or life-limiting conditions. The guideline covered multiple topics related to (refractory) symptom treatment, advance care planning and shared-decision making, organisation of care, psychosocial care, and loss and bereavement. We established six main working groups that formulated 38 clinical questions for which we identified evidence by updating two existing systematic literature searches. The GRADE (CERQual) methodology was used for appraisal of evidence. Furthermore, we searched for additional literature such as existing guidelines and textbooks to deal with lack of evidence.

RESULTS

The two systematic literature searches yielded a total of 29 RCTs or systematic reviews of RCTs on paediatric palliative care interventions and 22 qualitative studies on barriers and facilitators of advance care planning and shared decision-making. We identified evidence for 14 out of 38 clinical questions. Furthermore, we were able to select additional literature (29 guidelines, two textbooks, and 10 systematic reviews) to deal with lack of evidence.

CONCLUSIONS

The revised Dutch paediatric palliative care guideline addresses many topics. However, there is limited evidence to base recommendations upon. Our methodology will combine the existing evidence in scientific literature, additional literature, expert knowledge, and perspectives of patients and their families to provide recommendations.

Effect of expiratory muscle training on peak cough flow in children and adolescents with cystic fibrosis: A randomized controlled trial

BACKGROUND

Cough is an important defense and airway clearance mechanism for removing thick and viscous secretions in cystic fibrosis (CF). The primary aim of this study was to investigate the effect of expiratory muscle training (EMT) on peak cough flow (PCF) and secondly on respiratory muscle functions, functional exercise capacity, and quality of life (QoL) in CF.

METHODS

Thirty patients were randomized as training and sham groups. Both groups were trained with the EMT protocol, which involved twice per day for at least 5 days per week for 6 weeks. The training intensity in the training group was 30% of the maximal expiratory pressure (MEP). In the sham group, it remained at the lowest pressure (5 cmH₂ O). The primary outcome was PCF. The secondary outcomes were MEP, maximal inspiratory pressure (MIP), spirometric measures, six-minute walking distance (6MWD), and QoL (Cystic Fibrosis Questionnaire-Revised).

RESULTS

Twenty-eight patients completed the study. Changes in PCF (p = .041) and MEP (p = .003) were higher in the training group than the sham group. Also, treatment burden (p = .008), digestive symptoms (p = .019), and vitality (p = .042) in QoL were more improved in the training group. MIP (p = .028) and 6MWD (p = .035) changed significantly only in the training group. Spirometric measurements did not change (p > .05).

CONCLUSIONS

The results of the study show that EMT could improve PCF, MEP, treatment burden, digestive symptoms, and vitality domains of QoL in patients with CF. Moreover, MIP and functional exercise capacity improved in the training group with EMT.

Respiratory muscle training for cystic fibrosis

BACKGROUND

Cystic fibrosis is the most common autosomal recessive disease in white populations, and causes respiratory dysfunction in the majority of individuals. Numerous types of respiratory muscle training to improve respiratory function and health-related quality of life in people with cystic fibrosis have been reported in the literature. Hence a systematic review of the literature is needed to establish the effectiveness of respiratory muscle training (either inspiratory or expiratory muscle training) on clinical outcomes in cystic fibrosis. This is an update of a previously published review.

OBJECTIVES

To determine the effectiveness of respiratory muscle training on clinical outcomes in people with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Date of most recent search: 11 June 2020. A hand search of the Journal of Cystic Fibrosis and Pediatric Pulmonology was performed, along with an electronic search of online trial databases. Date of most recent search: 05 October 2020.

SELECTION CRITERIA

Randomised controlled studies comparing respiratory muscle training with a control group in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Review authors independently selected articles for inclusion, evaluated the methodological quality of the studies, and extracted data. Additional information was sought from trial authors where necessary. The quality of the evidence was assessed using the GRADE system.

MAIN RESULTS

Authors identified 20 studies, of which 10 studies with 238 participants met the review's inclusion criteria. There was wide variation in the methodological and written quality of the included studies. Four of the 10 included studies were published as abstracts only and lacked concise details, thus limiting the information available. Eight studies were parallel studies and two of a cross-over design. Respiratory muscle training interventions varied dramatically, with frequency, intensity and duration ranging from thrice weekly to twice daily, 20% to 80% of maximal effort, and 10 to 30 minutes, respectively. Participant numbers ranged from 11 to 39 participants in the included studies; five studies were in adults only, one in children only and four in a combination of children and adults. No differences between treatment and control were reported in the primary outcome of pulmonary function (forced expiratory volume in one second and forced vital capacity) or postural stability (very low-quality evidence). Although no change was reported in exercise capacity as assessed by the maximum rate of oxygen use and distance completed in a six minute walk test, a 10% improvement in exercise duration was found when working at 60% of maximal effort in one study (n = 20) (very low-quality evidence). In a further study (n = 18), when working at 80% of maximal effort, health-related quality of life improved in the mastery and emotion domains (very low-quality evidence). With regards to the review's secondary outcomes, one study (n = 11) found a change in intramural pressure, functional residual capacity and maximal inspiratory pressure following training (very low-quality evidence). Another study (n=36) reported improvements in maximal inspiratory pressure following training (P < 0.001) (very low-quality evidence). A further study (n = 22) reported that respiratory muscle endurance was longer in the training group (P < 0.01). No studies reported significant differences on any other secondary outcomes. Meta-analyses could not be performed due to a lack of consistency and insufficient detail in reported outcome measures.

AUTHORS' CONCLUSIONS

There is insufficient evidence to suggest whether this intervention is beneficial or not. Healthcare practitioners should consider the use of respiratory muscle training on a case-by-case basis. Further research of reputable methodological quality is needed to determine the effectiveness of respiratory muscle training in people with cystic fibrosis. Researchers should consider the following clinical outcomes in future studies; respiratory muscle function, pulmonary function, exercise capacity, hospital admissions, and health-related quality of life. Sensory-perceptual changes, such as respiratory effort sensation (e.g. rating of perceived breathlessness) and peripheral effort sensation (e.g. rating of perceived exertion) may also help to elucidate mechanisms underpinning the effectiveness of respiratory muscle training.

Do pulmonary and extrapulmonary features differ among cystic fibrosis, primary ciliary dyskinesia, and healthy children?

BACKGROUND

Primary ciliary dyskinesia (PCD) is generally likened to cystic fibrosis (CF) due to similarities in impaired mucociliary clearance and some other symptoms. The aim of our study was to investigate pulmonary and extrapulmonary characteristics of children with CF and PCD since no studies have addressed respiratory muscle strength in children with PCD and to compare the results to those obtained from healthy age-matched controls.

METHODS

Pulmonary and extrapulmonary characteristics were assessed by 6-min walk test, spirometry, maximum inspiratory and expiratory pressure measurements, and knee extensor strength test in the children with CF, PCD, and healthy controls.

RESULTS

Children with PCD and CF had similar PFT results, except forced expiratory flow between 25% and 75% of vital capacity (FEF_25-75 ) which was lower in PCD (p = .04). Maximum inspiratory pressure (MIP) value was lower in the children with CF compared with the healthy controls (p = .016), MEP value of the children with PCD was worse than those with CF and healthy controls (p = .013 and p = .013), respectively. 6-min walk test (6MWT) distance of the children with CF was lower than their healthy counterparts (p = .003). Knee extensor muscle strength differed among the children with PCD, CF, and healthy control groups, but post hoc test failed to show statistical significance (p = .010).

CONCLUSION

Children with CF and PCD had some impairments in pulmonary functions, respiratory muscle strength, functional capacity, and peripheral muscle strength compared with healthy children. However, the unique characteristics of each disease should be considered during physiotherapy assessment and treatment. The clinicians may especially focus on the respiratory and peripheral muscle strength of the children with PCD.

Impacts of Respiratory Muscle Training on Respiratory Functions, Maximal Exercise Capacity, Functional Performance, and Quality of Life in School-Aged Children with Postoperative Congenital Diaphragmatic Hernia

Objectives

Congenital diaphragmatic hernia (CDH) is a birth defect affecting the respiratory functions, functional performance, and quality of life (QOL) in school-aged children. Rarely have studies been conducted to evaluate the impacts of respiratory muscle training on school-aged children with postoperative CDH. The current study was designed to evaluate the impacts of respiratory muscle training on respiratory function, maximal exercise capacity, functional performance, and QOL in these children.

Methods

This study is a randomized control study. 40 children with CDH (age: 9-11 years) were assigned randomly into two groups. The first group conducted an incentive spirometer exercise combined with inspiratory muscle training (study group, n = 20), whereas the second group conducted only incentive spirometer exercise (control group, n = 20), thrice weekly for twelve consecutive weeks. Respiratory functions, maximal exercise capacity, functional performance, and pediatric quality of life inventory (PedsQL) were assessed before and after the treatment program. Results. Regarding the posttreatment analysis, the study group showed significant improvements in all outcome measures (FVC%, p < 0.001; FEV1%, p = 0.002; VO₂max, p = 0.008; VE/VCO₂ slope, p = 0.002; 6-MWT, p < 0.001; and PedsQL, p < 0.001), whereas the control group did not show significant changes (p > 0.05).

Conclusion

Respiratory muscle training may improve respiratory functions, maximal exercise capacities, functional performance, and QOL in children with postoperative CDH. Clinical commendations have to be considered to include respiratory muscle training in pulmonary rehabilitation programs in children with a history of CDH.

Methodologies of inspiratory muscle training techniques in obstructive lung diseases

Background: Inspiratory muscle training (IMT) is a non-pharmacological, non-invasive therapeutic method that can improve the quality of life in patients with obstructive lung diseases. The effectiveness of IMT may depends on the type of the device used in the training and the parameters of the training programme. Objectives: The aim of the review was to present different techniques and protocols of IMT used in patients with obstructive lung diseases. Methods: The MEDLINE and EMBASE were searched to identify the potentially eligible publications from the previous 5 years. The various protocols of IMT used in different studies were analysed and described in detail. Results: A database search identified 333 records, of which 22 were included into the final analysis. All of the finally analysed studies were conducted in patients with chronic obstructive pulmonary disease (COPD). The protocols of IMT used in the studies differed in the type of the device used, the duration of the training programme, the number and the duration of training sessions, the initial load, and the rate at which the load was changed during the training. Conclusions: IMT is used mainly in studies on patients with COPD and not with asthma. There is no one approved training programme for IMT. The most predominant type of IMT is a training with threshold loading. The most frequently used devices for IMT are POWERbreath and Threshold IMT. The protocols of IMT used in the studies are very diverse.

Assessing the Perceptions of Inspiratory Muscle Training in Children With Cystic Fibrosis and Their Multidisciplinary Team: Mixed-Methods Study

BACKGROUND

Little is known about the opinions or perceived benefits of an inspiratory muscle training intervention in patients with cystic fibrosis and their multidisciplinary team.

OBJECTIVE

The aim of this qualitative study was to examine patients' and multidisciplinary teams' views on inspiratory muscle training to inform and tailor future interventions.

METHODS

Individual, semistructured interviews were conducted to evaluate participants' perspectives of a 4-week inspiratory muscle training intervention. In this study, 8 of 13 individuals involved in the inspiratory muscle training program (5 children aged 11-14 years; 2 physiotherapists; and 1 respiratory physician) participated. Interviews were transcribed verbatim, analyzed using thematic analyses, and then coded into relevant themes.

RESULTS

Four key themes emerged: acceptability, facilitators, barriers, and recommendations. While fun, enjoyment, and improved perceived physical ability were reported by children and their multidisciplinary team following the inspiratory muscle training program, the multidisciplinary team identified factors such as time and cost as key barriers.

CONCLUSIONS

A short inspiratory muscle training program was perceived to have positive effects on the physical ability and psychosocial health of children with cystic fibrosis. These findings highlight the importance of obtaining participants' and multidisciplinary teams' perceptions and recommendations to ensure the efficacy and optimal design of future inspiratory muscle training protocols.

The effects of inspiratory muscle training on exercise capacity, dyspnea and respiratory functions in lung transplantation candidates: a randomized controlled trial

OBJECTIVE

To investigate whether inspiratory muscle training would contribute to the improvement of exercise capacity, dyspnea perception and respiratory functions in lung transplantation candidates.

DESIGN

Prospective randomized controlled trial.

SETTING

Pulmonary Rehabilitation center.

SUBJECTS

A total of 34 patients with severe lung disease requiring lung transplantation were randomly allocated to either pulmonary rehabilitation plus inspiratory muscle training group (PR + IMT group, n = 17) or pulmonary rehabilitation group (PR group, n = 17) before any lung transplantation operation.

METHODS

All patients underwent supervised pulmonary rehabilitation program on two days per week for three months. The PR + IMT group received inspiratory muscle training in addition to the standard pulmonary rehabilitation program. The 6-minute walk test, maximal inspiratory pressure, modified Medical Research Concile dyspnea scores and spirometric parameters were measured for each patient.

RESULTS

The PR + IMT group had statistically significantly increased in walking distance (100 m, P = 0.03), maximum inspiratory pressure (26 cmH₂O, P = 0.001) and alveolar volume ratio of carbonmonoxide diffusion capacity (9%, P = 0.02) than PR group. Although both groups demonstrated a statistically significant decrease in the dyspnea score, no significant differences were found between the groups ( P = 0.075). There was no change in spirometric variables in both groups.

CONCLUSION

A greater increase in exercise capacity was observed in the PR + IMT group. Our study showed that inspiratory muscle training improved exercise capacity even further and increased the benefits provided by pulmonary rehabilitation.

Respiratory muscle training for cystic fibrosis

BACKGROUND

Cystic fibrosis is the most common autosomal recessive disease in white populations, and causes respiratory dysfunction in the majority of individuals. Numerous types of respiratory muscle training to improve respiratory function and health-related quality of life in people with cystic fibrosis have been reported in the literature. Hence a systematic review of the literature is needed to establish the effectiveness of respiratory muscle training (either inspiratory or expiratory muscle training) on clinical outcomes in cystic fibrosis. This is an update of a previously published review.

OBJECTIVES

To determine the effectiveness of respiratory muscle training on clinical outcomes in people with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of most recent search: 17 April 2018.A hand search of the Journal of Cystic Fibrosis and Pediatric Pulmonology was performed, along with an electronic search of online trial databases up until 07 May 2018.

SELECTION CRITERIA

Randomised controlled studies comparing respiratory muscle training with a control group in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Review authors independently selected articles for inclusion, evaluated the methodological quality of the studies, and extracted data. Additional information was sought from trial authors where necessary. The quality of the evidence was assessed using the GRADE system MAIN RESULTS: Authors identified 19 studies, of which nine studies with 202 participants met the review's inclusion criteria. There was wide variation in the methodological and written quality of the included studies. Four of the nine included studies were published as abstracts only and lacking concise details, thus limiting the information available. Seven studies were parallel studies and two of a cross-over design. Respiratory muscle training interventions varied dramatically, with frequency, intensity and duration ranging from thrice weekly to twice daily, 20% to 80% of maximal effort, and 10 to 30 minutes, respectively. Participant numbers ranged from 11 to 39 participants in the included studies; five studies were in adults only and four in a combination of children and adults.No significant improvement was reported in the primary outcome of pulmonary function (forced expiratory volume in one second and forced vital capacity) (very low-quality evidence). Although no change was reported in exercise capacity as assessed by the maximum rate of oxygen use, a 10% improvement in exercise duration was found when working at 60% of maximal effort in one study (n = 20) (very low-quality evidence). In a further study (n = 18), when working at 80% of maximal effort, health-related quality of life improved in the mastery and emotion domains (very low-quality evidence). With regards to the review's secondary outcomes, one study (n = 11) found a significant change in intramural pressure, functional residual capacity and maximal inspiratory pressure following training (low-quality evidence). A further study (n = 22) reported that respiratory muscle endurance was significantly longer in the training group (P < 0.01). No studies reported on any other secondary outcomes. Meta-analyses could not be performed due to a lack of consistency and insufficient detail in reported outcome measures.

AUTHORS' CONCLUSIONS

There is insufficient evidence to suggest whether this intervention is beneficial or not. Healthcare practitioners should consider the use of respiratory muscle training on a case-by-case basis. Further research of reputable methodological quality is needed to determine the effectiveness of respiratory muscle training in people with cystic fibrosis. Researchers should consider the following clinical outcomes in future studies; respiratory muscle function, pulmonary function, exercise capacity, hospital admissions, and health-related quality of life. Sensory-perceptual changes, such as respiratory effort sensation (e.g. rating of perceived breathlessness) and peripheral effort sensation (e.g. rating of perceived exertion) may also help to elucidate mechanisms underpinning the effectiveness of respiratory muscle training.

Reference Values for Inspiratory Muscle Endurance in Healthy Children and Adolescents

Aims

To generate reference values for two inspiratory muscle endurance (IME) protocols in healthy children and adolescents.

Materials and methods

This is an observational, cross-sectional study, in healthy children and adolescents from 4 to 18 years of age. Weight, height, maximal inspiratory pressure (MIP) and IME were measured using two protocols. A fixed load of 30% of MIP with a 10% increment every 2 minutes was used in the incremental threshold loading protocol. As for the maximal loading protocol, a fixed load of 70% of MIP was used and the time limit (Tlim) achieved until fatigue was measured.

Results

A total of 462 participants were included, 281 corresponding to the incremental loading protocol and 181 to maximal loading. There were moderate and positive correlations between IME and age, MIP, weight and height in the incremental threshold loading. However, the regression model demonstrated that MIP and age were the best variables to predict the IME. Otherwise, weak and positive correlations with age, weight and height were found in the maximal loading. Only age and height influenced endurance in the regression model. The predictive power (r²) of the incremental threshold loading protocol was 0.65, while the maximal loading was 0.15. The reproducibility measured by the intraclass correlation coefficient (ICC) was higher in the incremental loading (0.96) compared to the maximal loading test (0.69).

Conclusion

IME in healthy children and adolescents can be explained by age, height and MIP. The incremental threshold loading protocol showed more reliable results and should be the model of choice to evaluate IME in the pediatric age group.

Inspiratory muscle training in pediatrics: main indications and technical characteristics of the protocols

Abstract Introduction: Inspiratory muscle training (IMT) is a resource widely used in pediatrics. However, there is great variability in relation to the characteristics of the protocols used. Objective: To identify the main clinical conditions and IMT protocols used in the pediatric age group. Methods: Integrative review of the literature by searching on Pubmed, Scielo, PEDro and EMBASE databases using the following strategy: threshold OR inspiratory muscle training OR muscle endurance OR muscle resistance OR endurance training OR maximal inspiratory pressure AND respiratory muscle. We have selected clinical trials that performed IMT in children and adolescents (0 to 18 years old), with a clinical diagnosis, and published in English, Portuguese and Spanish. Results: 17 studies were included. From these, 11 underwent IMT in patients with some neuromuscular disorder, being Duchenne Muscular Dystrophy the most common. The selected articles included a total sample of 327 participants. As for the characteristics of the protocols, 7 performed strength training, 5 endurance and 5 strength and endurance. The training load ranged from 30 to 80% of maximal inspiratory pressure. Moreover, 8 studies performed IMT twice daily and the session duration and the training period varied between 10 and 30 minutes, and from 3 weeks to 24 months, respectively. Conclusion: The IMT was used more frequently in patients with some neuromuscular disorder. Although there is no consensus as to the characteristics of the protocols, the choice of the load should take into account the purpose of IMT and the disease severity.

Physiotherapy management of cystic fibrosis

For many years physiotherapy for cystic fibrosis (CF) was synonymous with a daily routine of postural drainage and percussion. Improved longevity and a desire for independence, together with a clearer understanding of the pathophysiology of the disease, has led to the development of many airway clearance techniques. The contribution of ‘chest’ physiotherapy remained unchallenged until recent times when lack of robust evidence and the presentation of asymptomic infants and adults led some physiotherapists to question this traditional approach. As survival increases into the fourth and fifth decade unique complications have evolved and physiotherapy management is challenged with nonrespiratory aspects of treatment. This review will consider the evidence for, and current practice of airway clearance, the value of exercise and the emerging problems of musculoskeletal complications and incontinence.

Inspiratory muscle function in asthmatic and healthy subjects: influence of age, nutrition and physical activity

OBJECTIVE

To compare inspiratory muscle function (strength and endurance) between asthmatics and healthy controls, and the influence of age, nutritional status and physical activity on them.

METHODS

This is a cross-sectional study. Asthmatic and healthy subjects, aged 6 to 18 years old, recruited from two public schools in Southern Brazil were included in the study. Asthmatic subjects were selected using the criteria presented by the International Study on Asthma and Allergies in Children and control subjects based on the absence of respiratory symptoms. Anthropometric data was measured, body mass index calculated and subjects classified as normal weight, overweight or obese. Physical activity levels, maximum inspiratory pressure (MIP) and inspiratory muscle endurance (IME) were also evaluated.

RESULTS

A total of 314 participants were included, separated into control group (181) and asthmatics (133), with a total mean age of 11 years. When both groups were compared, there were no significant differences in both MIP and IME. However, when groups were analyzed subdivided in children and adolescents, IME was significantly reduced (p = 0.003) in asthmatic adolescents. Indeed, when groups were also stratified considering the nutritional status, IME showed a reduction in asthmatic adolescents with overweight (p = 0.042) and obesity (p = 0.041) when compared to healthy controls. No effects of physical activity levels between groups were found.

CONCLUSIONS

Results demonstrate a reduction in the IME in asthmatic adolescents with overweight and obesity, indicating an association between asthma, nutritional status and respiratory muscle function.

Reference Equation for Respiratory Pressures in Pediatric Population: A Multicenter Study

Previous studies have proposed only one prediction equation for respiratory muscle strength without taking into consideration differences between ages in pediatric population. In addition, those researches were single-center studies. The objective of this study was to establish reference equations for maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) in children and teenagers. In a multicenter study, 450 healthy volunteers were evaluated (aged 6–18yrs). There were included volunteers with normal lung function. We excluded volunteers who could not perform the tests; participated in physical activity more than twice a week; were born prematurely; smokers; chronic respiratory, cardiologic, and/or neurologic diseases; had acute respiratory disease during the prior three weeks. The volunteers were divided into two groups: Group 6–11 (6–11yrs) and Group 12–18 (12–18yrs). PImax and PEmax were measured according to statement. The mean PImax value was 85.6 (95%IC 83.6–87.6 cmH₂O), and PEmax 84.6 (95%IC 85.5–86.2 cmH₂O). The prediction equations for PImax and PEmax for Group 6–11 were 37.458–0.559 + (age * 3.253) + (BMI * 0.843) + (age * gender * 0.985); and 38.556 + 15.892 + (age * 3.023) + (BMI * 0.579) + (age * gender * 0.881), respectively (R² = 0.34 and 0.31, P<0.001). The equations for Group 12–18 were 92.472 + (gender * 9.894) + 7.103, (R² = 0.27, P = 0.006) for PImax; and 68.113 + (gender * 17.022) + 6.46 + (BMI * 0.927), (R² = 0.34, P<0.0001) for PEmax. This multicenter study determined the respiratory muscle strength prediction equations for children and teenagers.

Determinants of respiratory pump function in patients with cystic fibrosis

Respiratory failure constitutes the major cause of morbidity and mortality in patients with Cystic Fibrosis (CF). Respiratory failure could either be due to lung parenchyma damage or to insufficiency of the respiratory pump which consists of the respiratory muscles, the rib cage and the neuromuscular transmission pathways. Airway obstruction, hyperinflation and malnutrition have been historically recognised as the major determinants of respiratory pump dysfunction in CF. Recent research has identified chronic infection, genetic predisposition, dietary and pharmaceutical interventions as possible additional determinants of this impairment. Furthermore, new methodological approaches in assessing respiratory pump function have led to a better understanding of the pathogenesis of respiratory pump failure in CF. Finally, respiratory muscle function could be partially preserved in CF patients with structured interventions such as aerobic exercise, inspiratory muscle training and non-invasive ventilation and CF patients could consequently be relatively protected from respiratory fatigue and respiratory failure.

Pulmonary rehabilitation for respiratory disorders other than chronic obstructive pulmonary disease

Pulmonary rehabilitation (PR) is an important therapeutic intervention that should no longer be considered suitable only for patients with chronic obstructive pulmonary disease (COPD). A strong rationale exists for providing PR to persons with a broad range of respiratory disorders other than COPD. Evidence shows that PR for these patients is feasible, safe and effective. A disease-relevant approach should be undertaken, based on individual patients' needs. Further research is needed to better understand the optimal program content, duration and outcomes measures, to enable diverse patients to achieve maximal benefits of PR.

Equações internacionais superestimam a força muscular ventilatória em crianças e adolescentes com fibrose cística

O objetivo deste estudo foi comparar os resultados da normalização dos dados de força muscular ventilatória utilizando-se três equações de referência internacionais e uma nacional em crianças e adolescentes com fibrose cística (FC). Estudo retrospectivo, no qual foram incluídos pacientes com FC, idade entre 8 e 12 anos e acompanhamento ambulatorial regular. Foram coletados dados demográficos e variáveis antropométricas. Todos os pacientes incluídos deveriam ter realizado teste de força muscular ventilatória e espirometria nos últimos 12 meses. A normalização dos resultados foi realizada utilizando-se as variáveis preditoras requeridas em cada equação estudada. Os dados foram comparados utilizando-se uma ANOVA de uma via. Foram incluídos 24 pacientes, 62,5% masculinos, média de idade 10,5±1,53 anos, estatura 138,0±0,08 cm, massa corporal 34,6±9,07 kg, VEF1 93,29±29,02% e CVF 103,78±26,12%. As pressões (cmH2O) inspiratória (PIMAX) e expiratória (PEMAX) máximas encontradas foram 92,1±22,8 e 98,9±24,5, respectivamente. Após a normalização pelas diferentes equações, demonstrou-se que as internacionais tendem a superestimar os achados para a nossa população. A equação nacional apresentou valores médios previstos significativamente (p<0,05) menores para PIMAX e PEMAX em comparação com as equações internacionais, sendo que estas classificariam a PIMAX como acima do normal (>100%) em 91,6, 79,1, e 75,0% dos sujeitos e a PEMAX em 66,6, 87,5 e 50%, enquanto a equação nacional estimaria apenas 50,0 e 37,5% dos indivíduos, respectivamente. A normalização dos resultados de força muscular ventilatória em crianças e adolescentes entre 8 e 12 anos com FC utilizando-se equações internacionais superestimam os valores das pressões respiratórias máximas.

Inspiratory muscle training for cystic fibrosis

BACKGROUND

Cystic fibrosis is the most common life-limiting genetic condition in Caucasians and the life-expectancy of those newly diagnosed is increasing. Inspiratory muscle training may be a way of improving the lung function and quality of life of people with cystic fibrosis. Hence there is a need to establish whether this intervention is beneficial.

OBJECTIVES

To determine the effect of inspiratory muscle training on health-related quality of life, pulmonary function and exercise tolerance.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of most recent search: 08 July 2013.

SELECTION CRITERIA

Randomised or quasi-randomised clinical controlled trials comparing different inspiratory muscle training regimens with each other or a control in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Three review authors independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies.

MAIN RESULTS

Fourteen studies were identified. Of these eight studies with 180 participants met the review inclusion criteria. There was wide variation in the quality of the included studies. Data were not published in sufficient detail or with sufficiently similar outcome measures in these studies to perform meta-analyses.

AUTHORS' CONCLUSIONS

We have not found any evidence to suggest that this treatment is either beneficial or not. We would advise that practitioners evaluate on a case-by-case basis whether or not to employ this therapy. We recommend that future studies make more use of health-related quality of life and exercise tolerance measures; and that there is an agreement upon a single standard measure of classifying the clinical status of the participants.

Benefits of combining inspiratory muscle with 'whole muscle' training in children with cystic fibrosis: a randomised controlled trial

BACKGROUND

The purpose of this study (randomised controlled trial) was to assess the effects of an 8-week combined 'whole muscle' (resistance+aerobic) and inspiratory muscle training (IMT) on lung volume, inspiratory muscle strength (PImax) and cardiorespiratory fitness (VO2 peak) (primary outcomes), and dynamic muscle strength, body composition and quality of life in paediatric outpatients with CF (cystic fibrosis, secondary outcomes). We also determined the effects of a detraining period.

METHODS

Participants were randomly allocated with a block on gender to a control (standard therapy) or intervention group (initial n=10 (6 boys) in each group; age 10±1 and 11±1 years). The latter group performed a combined programme (IMT (2 sessions/day) and aerobic+strength exercises (3 days/week, in-hospital)) that was followed by a 4-week detraining period. All participants were evaluated at baseline, post-training and detraining.

RESULTS

Adherence to the training programme averaged 97.5%±1.7%. There was a significant interaction (group×time) effect for PImax, VO2peak and five-repetition maximum strength (leg-press, bench-press, seated-row) (all (p<0.001), and also for %fat (p<0.023) and %fat-free mass (p=0.001), with training exerting a significant beneficial effect only in the intervention group, which was maintained after detraining for PImax and leg-press.

CONCLUSION

The relatively short-term (8-week) training programme used here induced significant benefits in important health phenotypes of paediatric patients with CF. IMT is an easily applicable intervention that could be included, together with supervised exercise training in the standard care of these patients.

Efeitos do treinamento muscular inspiratório em universitários tabagistas e não tabagistas

O hábito de fumar pode reduzir a capacidade aeróbica, aumentar a resistência ao fluxo aéreo e afetar a função dos músculos respiratórios. O objetivo deste estudo foi comparar os efeitos do Treinamento Muscular Inspiratório (TMI) entre dois grupos: tabagistas e não tabagistas. Participaram 44 voluntários universitários, divididos em dois grupos: tabagistas (GT), composto por 20 indivíduos (25,60±7,01 anos) e não tabagistas, constituindo o Grupo Controle (GC), composto por 24 voluntários (24,08±7,52 anos). Ambos os grupos foram submetidos ao TMI, por meio do uso do manovacuômetro aneroide, com duração de 6 semanas, sendo 3 sessões semanais, totalizando 18 sessões. Os resultados mostraram diferença estatisticamente significativa (p<0,05) pós-TMI no GC para as variáveis: Pressão Inspiratória Máxima (PImáx), Pico de Fluxo Expiratório (PFE), Pressão Arterial Média ao repouso (PAM pré-TC6) e Teste de Caminhada de Seis Minutos (TC6). No GT, houve diferença estatisticamente significativa pós-TMI para as variáveis: PImáx, PFE, TC6 e saturação periférica de oxigênio após o TC6 (SpO2 pós-imediata). A comparação das médias das variáveis entre GT e GC mostrou diferença estatisticamente significativa no pós-TMI para as variáveis PImáx e PFE. A variável TC6 não apresentou diferença estatisticamente significativa. Conclui-se que o TMI proporcionou um aumento significativo da força muscular inspiratória, melhora da função pulmonar e melhora do desempenho físico nos indivíduos estudados.

Inspiratory muscle training in bronchiectasis patients: a prospective randomized controlled study

OBJECTIVE

To investigate the efficacy and feasibility of home-based inspiratory muscle training in patients with bronchiectasis.

DESIGN

A prospective, single-blind, randomized, controlled study.

SETTING

Outpatient clinic of a tertiary care medical centre.

METHODS

Twenty-six patients with bronchiectasis were randomly divided into inspiratory muscle training and control groups. In the inspiratory muscle training group (n = 13), the training programme started with an intensity of 30% maximal inspiratory pressure (MIP), which was increased by 2 cmH(2)O each week, for 30 minutes daily, 5 days a week for eight weeks. The control group (n = 13) did not receive inspiratory muscle training. Main outcome measures included spirometry, resting oxyhaemoglobin saturation by pulse oximetry (SpO(2)), lowest SpO(2) and Borg Scale during 6-minute walking tests, 6-minute walking distance (6MWD), 6-minute walking work (6M(work)), MIP, maximal expiratory pressure (MEP) and St George's Respiratory Questionnaire.

RESULTS

There were significant differences in change from baseline in 6MWD (411.9 (133.5) vs. 473.2 (117.2) m, P = 0.021), 6M(work) (21 051.0 (8286.7) vs. 23 915.5 (8343.0) kg-m, P = 0.022), MIP (60.8 (21.8) vs. 84.6 (29.0) cmH(2)O, P = 0.004), and MEP (72.3 (31.1) vs. 104.2 (35.7) cmH(2)O, P = 0.004) in the inspiratory muscle training group. Significant improvements in both MIP (23.8 (25.3) vs. 2.3 (16.4) cmH(2)O, adjusted P-value = 0.005) and MEP (31.9 (30.8) vs. 11.5 (20.8) cmH(2)O, adjusted P-value = 0.038) levels after adjusting for age by linear regression analysis were observed between groups.

CONCLUSIONS

An eight-week home-based inspiratory muscle training is feasible and effective in improving both inspiratory and expiratory muscle strength, but has no effect on respiratory function and quality of life in patients with bronchiectasis.

Lifestyle and the Respiratory Health of Children

This article offers a review of the potential influences of personal lifestyle on respiratory health in children, looking at both healthy individuals and those with respiratory disorders. As with many aspects of health, regular physical activity, an appropriate diet, and avoidance of obesity and cigarette smoke all contribute to optimal development of the healthy child. An active lifestyle is associated with greater static and dynamic lung volumes, greater efficiency of the ventilatory process, and an optimization of breathing patterns. The risk of upper respiratory infections is also reduced in those maintaining a moderate level of physical activity. Maternal smoking during pregnancy, as well as active and passive smoking, all have an adverse influence on lung function in the child, the largest effects being on dynamic lung volumes. The risk of developing asthma seems reduced in children who maintain a normal body mass and are physically active. A program of graded physical activity is of therapeutic value in a number of established respiratory conditions, including asthma, cystic fibrosis, and ventilatory impairment from neuromuscular disorders. Exercise carries a slight risk of fatalities from asthma and anaphylactic reactions. In designing an optimal physical activity program, it is also important to guard against the hazards of deep oronasal breathing, including the precipitation of bronchospasm by the inhalation of cold, dry air and pollens; an increased exposure to atmospheric pollutants (reducing and oxidant smog, fine and ultra-fine particulates, and carbon monoxide); and possible long-term dangers from chlorine derivatives in the atmosphere of indoor swimming pools.

Supramaximal verification of peak oxygen uptake in adolescents with cystic fibrosis

PURPOSE

To study whether peak oxygen uptake ((Equation is included in full-text article VO₂ peak), attained in traditional cardiopulmonary exercise testing (CPET) in adolescents with cystic fibrosis (CF), could be verified by a supramaximal exercise test.

METHODS

Sixteen adolescents with CF (forced expiratory volume in 1 second as % of predicted [range, 45%-117%]) volunteered and successively performed CPET and a supramaximal test (Steep Ramp Test [SRT] protocol).

RESULTS

Cardiopulmonary exercise testing and the SRT resulted in comparable cardiorespiratory peak values. We found no significant difference in oxygen uptake ((Equation is included in full-text article VO₂ peak/kg) between CPET and the SRT (38.9 ± 7.4 and 38.8 ± 8.5 mL min kg, respectively; P = .81). We found no systemic bias for CPET and SRT measurements of (Equation is included in full-text article VO₂  peak/kg and no differences between CPET and SRT (Equation is included in full-text article VO₂  peak values within and between the maximal and non-maximal effort groups (P > .4).

CONCLUSION

The (Equation is included in full-text article VO₂  peak measured in CPET seems to reflect the true (Equation is included in full-text article.)O2 peak in adolescents with CF.

A breath biofeedback computer game for children with cystic fibrosis

The authors sought to develop and test a breath-controlled video game using a digital spirometer that, by providing visual breath biofeedback, could promote awareness of breathing techniques in children with cystic fibrosis (CF). To assess improvement in game performance during hospitalizations for CF exacerbations, the authors conducted a trial on 10 inpatients. Subjects had at least five 15-minute exposures to a breath biofeedback game that challenged them to track a moving target using their breath. Subjects reacted positively to the breath tracking challenge. Repeated-measures analysis of variance of a tracking fidelity statistic showed improvement in eye-breath coordination over 5 sessions ( P = .026). It was concluded that an electronic breath game is safe and can improve breath awareness among children with CF. This technology could also contribute to awareness of respiratory symptoms and foster social ties among CF patients.

Correlação entre a composição corporal e força, resistência da musculatura respiratória e capacidade de exercício em pacientes com doença pulmonar obstrutiva crônica

Este estudo buscou correlações entre a composição corporal (aferida por métodos indiretos) e força, resistência da musculatura respiratória e capacidade de exercício em portadores de doença pulmonar obstrutiva crônica (DPOC). Os 30 voluntários, idosos, foram divididos em três grupos, dois de pacientes com DPOC, estáveis e controlados clinicamente, e um grupo controle, com indivíduos sem doenças pulmonares, selecionados na mesma faixa etária e biótipo daqueles com DPOC. Todos foram submetidos a espirometria e medidas das pressões respiratórias máximas para avaliação da força dos músculos respiratórios, teste de resistência dos músculos respiratórios, teste de caminhada de seis minutos (TC6'), medidas de dobras cutâneas e índice de massa corporal (IMC). Os sujeitos (6 mulheres e 24 homens) foram divididos em: grupo A, n=11, com DPOC moderado a grave (idade 69,5±10,5 anos, IMC 24,00±3,66 kg/m²); grupo B, n=10, com DPOC leve (71,1±8,1 anos, IMC 24,41±0,58 kg/m²); e grupo C controle, n=9 (70,1±5,9 anos, IMC 27,44±1,33 kg/m²). Apenas os valores de porcentagem de gordura corporal e distância caminhada (no TC6') apresentaram diferenças significativas entre os grupos. Os resultados não indicaram correlação significativa entre as variáveis analisadas. Embora a literatura aponte o estado nutricional como um dos fatores do comprometimento respiratório na DPOC, não foi encontrada correlação entre a composição corporal e os parâmetros respiratórios nos pacientes estudados.

Effects of inspiratory muscle training in cystic fibrosis: a systematic review

OBJECTIVE

We performed a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis.

DATA SOURCES

MEDLINE, EMBASE and CINAHL electronic databases were searched up to January 2008.

REVIEW METHODS

We performed a systematic review using the methodology outlined in the Cochrane Collaboration protocol. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (> 13 years of age); (2) an IMT group was compared to a sham IMT, no intervention or other intervention group; (3) the study used a randomized controlled trial or cross-over design; and (4) it was published in English. Data were abstracted and methodological quality was assessed independently by two reviewers.

RESULTS

The search strategy yielded 36 articles, of which two met the inclusion criteria. Both studies used a targeted or threshold device for IMT. Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which showed no difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength. One study demonstrated improvement in inspiratory muscle endurance.

CONCLUSION

The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear. Future research should investigate the characteristics of the subgroup of people with cystic fibrosis that might benefit most from IMT.

Dyspnoea in children. Does development alter the perception of breathlessness?

Dyspnoea, the perception of an unpleasant and/or uncomfortable sensation of breathlessness, offers several physiological, anatomical and teleological analogies with pain. Pain perception has been shown to exist in the newborn, suggesting that dyspnoea may also occur from birth onwards. The perception of breathlessness will be subservient to developmental changes in the behaviour of sensors and lung and muscular receptors implicated in dyspnoea, some of which are known to be active at time of birth. For example, perinatal resetting of the arterial chemoreceptor could lead to transient depression of the dyspnoeic response to hypoxia. However, though early evoked ventilatory responses and peripheral receptor maturation do exist, dyspnoea will only occur if the corresponding central neural circuitry undergoes parallel maturation. Our knowledge of dyspnoea in later childhood is based on a small number of clinical or psychophysical studies, predominantly dealing with asthma and exercise. There is a thus a clear need for systematic assessment of the existence and severity of dyspnoea sensing in younger children that takes into account its role as an alarm mechanism for triggering adaptive and/or protective responses.

Inspiratory muscle training for cystic fibrosis

BACKGROUND

Cystic fibrosis is the most common life-limiting genetic condition in Caucasians and the life-expectancy of those newly diagnosed is increasing. Inspiratory muscle training may be a way of improving the lung function and quality of life of people with cystic fibrosis. Hence there is a need to establish whether this intervention is beneficial.

OBJECTIVES

To determine the effect of inspiratory muscle training on health-related quality of life, pulmonary function and exercise tolerance.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials register comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Date of most recent search: April 2008.

SELECTION CRITERIA

Randomised or quasi-randomised clinical controlled trials comparing different inspiratory muscle training regimens with each other or a control in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Three review authors independently applied the inclusion and exclusion criteria to publications and assessed the quality of the included studies.

MAIN RESULTS

Seven studies were identified. Of these six studies with 140 participants met the review inclusion criteria. There was wide variation in the quality of the included studies. Data were not published in sufficient detail or with sufficiently similar outcome measures in these studies to perform meta-analyses.

AUTHORS' CONCLUSIONS

We have not found any evidence to suggest that this treatment is either beneficial or not. We would advise that practitioners evaluate on a case-by-case basis whether or not to employ this therapy. We recommend that future studies make more use of health-related quality of life and exercise tolerance measures; and that there is an agreement upon a single standard measure of classifying the clinical status of the participants.

Effect of respiratory rate on airway deadspace ventilation during exercise in cystic fibrosis

Gas exchange during exercise in patients with cystic fibrosis (CF) is characterised by an elevated physiological deadspace to tidal volume ratio. While this has been attributed to alveolar ventilation perfusion mismatch, there are other potential causes of the high proportion of wasted ventilation, including factors relating to the volume and the ventilation of the airway deadspace. CF (n = 6, F = 1, FEV1 26-63% pred) and control (n = 6, F = 2) subjects completed steady-state exercise on a cycle ergometer. Gas exchange was measured breath-by-breath and the volume of the airway deadspace (V(Daw)) determined using the equal areas method. Exercise data were interpolated to a CO2 output of 0.7 l/min. V(Daw) was similar in the two groups both at rest and during exercise. However, the airway deadspace ventilation (V(Daw)) (median (inter-quartile range)), patients, 6.8 (5.1-7.1) l/min; controls, 4.9 (3.5-5.6) l/min, P < 0.05) was significantly greater in the CF group due to a greater respiratory frequency. These results indicate that in CF patients, abnormally increased V(Daw) is an important contributor to the total (physiological) deadspace ventilation. Exercise performance in CF might be enhanced by efforts directed at facilitating an increase in exercise tidal volume and therefore the adoption of a more efficient pattern of breathing.

Inspiratory muscle training improves lung function and exercise capacity in adults with cystic fibrosis

STUDY OBJECTIVES

To investigate the effects of high-intensity inspiratory muscle training (IMT) on inspiratory muscle function (IMF), diaphragm thickness, lung function, physical work capacity (PWC), and psychosocial status in patients with cystic fibrosis (CF).

DESIGN

Twenty-nine adult patients with CF were randomly assigned to three groups. Two groups were required to complete an 8-week program of IMT in which the training intensity was set at either 80% of maximal effort (group 1; 9 patients) or 20% of maximal effort (group 2; 10 patients). A third group of patients did not participate in any form of training and acted as a control group (group 3; 10 patients).

INTERVENTIONS

In all patients, baseline and postintervention measures of IMF were determined by maximal inspiratory pressure (Pimax), and sustained Pimax (SPimax); pulmonary function, body composition, and physical activity status were also determined. In addition, diaphragm thickness was measured at functional residual capacity (FRC) and total lung capacity (TLC) [TDIcont], and the diaphragm thickening ratio (TR) was calculated (TR = thickness during Pimax at FRC/mean thickness at FRC). Subjects also completed an incremental cycle ergometer test to exhaustion and two symptom-related questionnaires, prior to and following training.

RESULTS

Following training, significant increases in Pimax and SPimax (p < 0.05), TDIcont (p < 0.05), TR (p < 0.05), vital capacity (p < 0.05), TLC (p < 0.05), and PWC (p < 0.05) were identified, and decreases in anxiety scores (p < 0.05) and depression scores (p < 0.01) were noted in group 1 patients compared to group 3 patients. Group 2 patients significantly improved Pimax and SPimax (both p < 0.05) only with respect to group 3 patients. No significant differences were observed in group 3 patients.

CONCLUSION

An 8-week program of high-intensity IMT resulted in significant benefits for CF patients, which included increased IMF and thickness of the diaphragm (during contraction), improved lung volumes, increased PWC, and improved psychosocial status.

Inspiratory muscle training for asthma

BACKGROUND

In moderate to severe chronic obstructive pulmonary disease there is good evidence of a generalised loss of muscle bulk (including the respiratory muscles). It is possible that similar loss of respiratory muscle strength occur particularly in more severe asthma related in part to the effects of steroid therapy. Thus the respiratory muscle function may well be of relevance in asthma and if dysfunctional, may be a suitable target for training.

OBJECTIVES

To evaluate the efficacy of inspiratory muscle training with an external resistive device in patients with asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2002), MEDLINE (January 1966 to March 2002), EMBASE (January 1985 to March 2002), CINAHL (to March 2002) and the UK National Research Register of trials (January 1982 to March 2002) and reference lists of articles. We also searched on line respiratory journals and contacted manufacturers of training devices to obtain trials.

SELECTION CRITERIA

All randomised-controlled trials that involved the use of an external inspiratory muscle training device versus a control (sham or no inspiratory training device) were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted data.

MAIN RESULTS

Five studies were included in the review with four of the studies being produced by the same group. PI(max) (maximum inspiratory pressure) reported in three studies with 76 patients showed significant improvement with inspiratory muscle training when compared to the control group (WMD 23.07 cmH(2)O, 95%CI 15.65 to 30.50). Unfortunately, due to the paucity of included studies and data no other outcome was reported by more than one study. Therefore it is not possible to confirm whether this increase seen with PI(max) translates into any measurable clinical benefit.

REVIEWER'S CONCLUSIONS

Currently there is insufficient evidence to suggest that inspiratory muscle training provides any clinical benefit to patients with asthma. Due to the limited availability of studies in this area there is a need for further trials evaluating the efficacy of inspiratory muscle training devices in patients with asthma. These studies should investigate asthmatics with a range of severity. They should investigate clinically relevant outcomes such as lung function, symptoms, exacerbation rate and concomitant medications.