Breathing techniques in patients with chronic obstructive pulmonary disease (COPD)

Feasibility of a telehealth breathing intervention for patients with idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a restrictive chronic lung disease that results in scarring of the tissue due to an unknown cause. Dyspnea is experienced by 90 % of patients and is correlated with reduced quality of life and survival times. Breathing techniques can improve perceived dyspnea, however, are not readily taught outside of inpatient hospital settings and pulmonary rehabilitation programs, the latter being accessed by only 3 % of patients with chronic lung disease. Telehealth may be an option to increase access to this imperative symptom management education to improve symptom management and patient outcomes.

AIMS

1) To determine the feasibility of a telehealth breathing intervention for patients living with IPF; 2) To determine the usability of the telehealth system; 3) To describe within-group changes in dyspnea, quality of life, anxiety, and depression.

DESIGN

A single-group, pre-post intervention.

METHODS

Study participants were recruited from community-dwelling patients living with IPF. Pre-intervention data was collected on symptoms using standardized questionnaires. Participants enrolled in one telehealth Zoom session per week over the course of four weeks and practiced breathing exercises 10-minutes per day. Following the intervention, participants completed post-intervention, feasibility, and usability questionnaires. Data were analyzed using descriptive statistics.

RESULTS

All feasibility benchmarks were met. Following the intervention, mean symptom scores improved, however were not statistically significant.

CONCLUSION

These data indicate that a telehealth breathing intervention is a feasible option to increase access to the symptom management strategy of breathing techniques to manage perceived dyspnea to positively influence symptoms experienced by patients living with idiopathic pulmonary fibrosis.

Effects of different inspiratory muscle training protocols on functional exercise capacity and respiratory and peripheral muscle strength in patients with chronic kidney disease: a randomized study

BACKGROUND

Pathological changes were observed in the diaphragm due to abnormal renal function in chronic kidney disease (CKD). Inspiratory muscle training (IMT) has been suggested for patients with CKD; however, the most appropriate intensity for IMT has not been determined. Therefore, this study aimed to investigate the effects of different IMT protocols on respiratory muscle strength, quadriceps femoris muscle strength (QMS), handgrip muscle strength (HGS), functional exercise capacity, quality of life (QoL), pulmonary function, dyspnoea, fatigue, balance, and physical activity (PA) levels in patients with CKD.

METHODS

This randomized, controlled, single-blind study included 47 patients and they were divided into three groups: Group 1 (n = 15, IMT with 10% maximal inspiratory pressure (MIP)), Group 2 (n = 16, IMT with 30% MIP), and Group 3(n = 16; IMT with 60% MIP). MIP, maximal expiratory pressure (MEP), 6-min walking test (6-MWT), QMS, HGS, QoL, pulmonary function, dyspnoea, fatigue, balance, and PA levels were assessed before and after eight weeks of IMT.

RESULTS

Increases in MIP, %MIP, 6-MWT distance, and %6-MWT were significantly higher in Groups 2 and 3 than in Group 1 after IMT (p < 0.05). MEP, %MEP, FEF25-75%, QMS, HGS, and QoL significantly increased; dyspnoea and fatigue decreased in all groups (p < 0.05). FVC, PEF, and PA improved only in Group 2, and balance improved in Groups 1 and 2 (p < 0.05).

CONCLUSIONS

IMT with 30% and 60% MIP similarly improves inspiratory muscle strength and functional exercise capacity. IMT with 30% is more effective in increasing PA. IMT is a beneficial method to enhance peripheral and expiratory muscle strength, respiratory function, QoL and balance, and reduce dyspnoea and fatigue. IMT with %30 could be an option for patients with CKD who do not tolerate higher intensities.

TRIAL REGISTRATION

This study was retrospectively registered (NCT06401135, 06/05/2024).

Effects of Breathing Exercises in Patients With Chronic Obstructive Pulmonary Disease: A Network Meta-analysis

OBJECTIVE

A network meta-analysis of randomized controlled trials (RCTs) was conducted to compare and rank the effectiveness of various breathing exercises for patients with chronic obstructive pulmonary disease (COPD).

DATA SOURCES

We searched PubMed, Web of Science, Embase, and the Cochrane Library databases to determine the articles.

STUDY SELECTION

Publications investigating the effect of breathing exercises on exercise capacity (six-minute walk test [6MWT]), pulmonary function (the ratio of the first second forced expiratory volume of forced vital capacity [FEV1/FVC]), quality of life (St George's Respiratory Questionnaire [SGRQ]), inspiratory muscle pressure (maximum inspiratory pressure [PImax]), and dyspnea (Borg scale) were searched.

DATA EXTRACTION

Data extracted by 2 researchers were entered into predesigned tables for data extraction. The quality of the literature was assessed using the Cochrane Collaboration's tool.

DATA SYNTHESIS

A total of 43 RCTs involving 1977 participants were analyzed. To boost exercise capacity, the top 2 exercises were inspiratory muscle training (75%), Chinese traditional fitness exercises (13%); To improve pulmonary function, the top 2 exercises were Chinese traditional fitness exercises (32%), diaphragm breathing (30%); To raise patients' quality of life, the top 2 exercises were yoga (52%), diaphragm breathing (28%); To increase inspiratory muscle pressure, the top 2 exercises were pursed-lip breathing (47%), Chinese traditional fitness exercises (25%); To improve dyspnea, the top 2 exercises were yoga (44%), inspiratory muscle training (22%).

CONCLUSIONS

Various breathing exercises for COPD patients confer benefits that manifest in diverse ways. Pulmonary rehabilitation specialists could administer personalized breathing exercises tailored to each patient's condition to attain optimal therapeutic outcomes.

Efficacy of diaphragmatic breathing exercise on respiratory, cognitive, and motor function outcomes in patients with stroke: a systematic review and meta-analysis

Background

Stroke disrupts the functions carried out by the brain such as the control of movement, sensation, and cognition. Disruption of movement control results in hemiparesis that affects the function of the diaphragm. Impaired function of the diaphragm can in turn affect many outcomes such as respiratory, cognitive, and motor function. The aim of this study is to carry out a systematic review and meta-analysis to determine the efficacy of diaphragmatic breathing exercise on respiratory, cognitive, and motor outcomes after stroke.

Method

The study was registered in PROSPERO (CRD42023422293). PubMED, Embase, Web of Science (WoS), PEDro, Scopus, and CENTRAL databases were searched until September 2023. Only randomized controlled trials comparing diaphragmatic breathing exercise with a control were included. Information on the study authors, time since stroke, mean age, height, weight, sex, and the protocols of the experimental and control interventions including intensity, mean scores on the outcomes such as respiratory, cognitive, and motor functions were extracted. Cochrane risks of bias assessment tool and PEDro scale were used to assess the risks of bias and methodological quality of the studies. Narrative synthesis and meta-analysis were used to summarize the results, which were then presented in tables, risk-of-bias graph, and forest plots. The meta-analysis was carried out on respiratory function [forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow (PEF)] and motor function (trunk impairment, and internal and external oblique muscles activity).

Results

Six studies consisting of 151 participants were included. The results of the meta-analyses showed that diaphragmatic breathing exercise is only superior to the control at improving respiratory function, FVC (MD = 0.90, 95% CI = 0.76 to 1.04, P < 0.00001), FEV1 (MD = 0.32, 95% CI = 0.11 to 0.52, P = 0.002), and PEF (MD = 1.48, 95% CI = 1.15 to 1.81, P < 0.00001).

Conclusion

There is limited evidence suggesting that diaphragmatic breathing exercise may help enhance respiratory function, which may help enhance recovery of function post stroke.

Systematic Review Registration

PROSPERO, identifier CRD42023422293.

Breathing pattern and its evaluation by muscle dynamometer md03

The purpose of the study was to determine the proportion of engagements of individual breathing sectors during 1-min physically active breathing at rest in 163 healthy, physically active participants (students of Physical Education and Sport). The research analyzed breathing movements through the muscle dynamometer MD03 (Hitron, Plzeň, Czech Republic). The proportion of engagements of the individual breathing sector in the group analyzed was determined based on measurement results. The lower breathing sector was engaged at 29.2%, the middle breathing sector at 31.0%, and the upper breathing sector at 39.8%. The largest observed difference between the involvement of individual breath sectors was 10.6% between the lower and upper breathing sectors. The muscle dynamometer MD03 may be instrumental for practising both localized breathing and full breath.

Effect of Liuzijue on pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: study protocol for a multicenter, non-randomized, prospective study

Background

Traditional Chinese exercise as a new pulmonary rehabilitation technique has been increasingly used and achieved good results in pulmonary rehabilitation of chronic obstructive pulmonary disease (COPD). The aim of this study is to investigate the protective effects of Liuzijue on exercise tolerance, lung function, and quality of life in patients with COPD.

Methods

This study is a multicenter, non-randomized, prospective study. Patients will be divided into a control group (CG) and a Liuzijue group (LG) based on their willingness to learn Liuzijue. None of the outcome assessors will know the grouping of patients. Participants in this study will be collected from stable COPD patients who are outpatients or inpatients in 3 centers in China since September 2021. Patients will meet the diagnostic criteria for GOLD stage I-II COPD (FEV₁% ≥ 0.5 and FEV₁/FVC < 0.7) and be aged 40 years or older. Patients voluntarily will take part in the clinical study and sign an informed consent form. All participants will follow their existing medication. For LG patients, Liuzijue training has been added. Patients will practice Liuzijue for more than 30 minutes a day, more than 5 days a week, and adhere to the training for 3 months. Outcome indicators are 6-minute walk test (6MWT), lung function (FEV₁%, FEV₁/FVC, MMEF, PEF), modified British Medical Research Council (mMRC) score, COPD assessment test score (CAT), acute exacerbations and changes in drug treatment.

Discussion

This study quantified the effect of Liuzijue on the pulmonary rehabilitation of COPD patients in the stable phase of the disease, and provided a basis for the use of Liuzijue in COPD patients.

Trial registration

Chinese clinical trial registry, ChiCTR2100048945. Date: 2021-07-19. http://www.chictr.org.cn/showproj.aspx?proj=129094

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03789-6.

A comparison of the effects of inspiratory muscle strength and endurance training on exercise capacity, respiratory muscle strength and endurance, and quality of life in pacemaker patients with heart failure: A randomized study

BACKGROUND

Studies have widely investigated the effects of inspiratory muscle strength training in patients with heart failure (HF). The effects of inspiratory muscle strength or endurance training on outcomes in patients with pacemakers have not been adequately studied.

OBJECTIVES

The aim was to compare the effects of inspiratory muscle strength and endurance training on exercise capacity, quality of life (QoL), peripheral and respiratory muscle strength, respiratory muscle endurance, pulmonary function, dyspnea, fatigue, and physical activity levels in pacemaker patients with HF.

METHODS

A randomized, controlled, double-blind study was conducted. Fourteen pacemaker patients with HF received inspiratory muscle strength training (IMST) at 50% of maximal inspiratory pressure (MIP), and 18 patients received endurance training (IMET) at 30% of MIP 7 days/8 weeks. Exercise capacity [6 min. walking test (6MWT) and the Incremental Shuttle Walking Test (ISWT)], pulmonary function, respiratory muscle strength [MIP, maximal expiratory pressure (MEP)], endurance, peripheral muscle strength, dyspnea, fatigue, QoL, and physical activity level were evaluated before and after.

RESULTS

Demographic characteristics were similar in IMST (3F/11M, 56.92 ± 7.61y, EF: 25%, ICD/CRT:11/3) and IMET (4F/14M, 56 ± 10.77y, EF: 30%, ICD/CRT:16/2) groups (p > 0.05). Significant improvements were present in MIP, MEP, respiratory muscle endurance, peripheral muscle strength, 6MWT and ISWT walking distances, dyspnea, QoL, physical activity level, fatigue scores within groups (p ≤ 0.05). However, there were no significant differences between the groups (p > 0.05). There were no significant improvements in FEV₁%, FVC%, FEV₁/FVC%, and FEF_25-75 within and between the groups (p > 0.05).

CONCLUSIONS

Inspiratory muscle strength and endurance training similarly improves respiratory and peripheral muscle strength, exercise capacity, QoL, physical activity level, and decreases dyspnea and fatigue and are safe and effective in pacemaker patients with HF.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov; study number: NCT03501355.

Effectiveness of 12-week inspiratory muscle training with manual therapy in patients with COPD: A randomized controlled study

The benefits of inspiratory muscle training (IMT) in patients with COPD were reported. However, its effects are limited in severe COPD patients. Further researches are required in new and complementary modalities demonstrating IMT efficacy in severe COPD patients. This study aims to investigate effects of manual therapy (MT) additional over IMT on functional capacity, respiratory muscle strength, pulmonary function, dyspnea, fatigue, and quality of life in severe COPD patients. Sixty patients with COPD in GOLD stage III-IV were included in this prospective single-blind randomized trial. Patients were randomly assigned to receive either MT additional over IMT at 40% of maximal inspiratory pressure (MIP) (n = 30) or only IMT (n = 30) for 12 weeks. MT group received MT during 12 weeks for 30 min additional to IMT. Pulmonary function, respiratory muscle strength, functional capacity, dyspnea, fatigue, and quality of life were evaluated by spirometry, mouth pressure device, six-minute walk test, Modified Medical Research Council (mMRC) dyspnea scale, fatigue severity scale, and St. George's Respiratory Questionnaire (SGRQ), respectively. MT group had significantly greater improvement in FEV1%, FVC%, PEF%, respiratory muscle strength, function, dyspnea, fatigue, and quality of life compared with IMT group (p < 0.05). 6MWT (p < 0.001, effect size Cohen's d: 0.915), MIP (p < 0.001, effect size Cohen's d: 1.235), and mMRC score (p < 0.001, effect size Cohen's d: 0.982) were significantly improved in IMT with MT group. This study demonstrated that subjects in IMT with MT group had improved outcomes in functional capacity, respiratory muscle strength, pulmonary function, dyspnea, fatigue perception, and quality of life compared with alone IMT group.

The effect of lung-conduction exercise in chronic obstructive pulmonary disease: Randomized, assessor-blind, multicenter pilot trial

BACKGROUND

Pulmonary rehabilitation (PR) is a management modality that improves the quality of life of patients with chronic obstructive pulmonary disease (COPD); however, PR is not readily accessible. Therefore, we developed lung-conduction exercises (LCE) that can be performed easily without any limitations. The purpose of this randomized, assessor-blind, multicenter pilot trial was to compare the effects of LCE with PR and standard care (SC) in COPD patients.

METHODS

Twenty-five participants who met the eligibility criteria were randomly allocated to the SC group (only medication, n = 9), LCE group (medication + LCE, 5 times a week, n = 8), or PR group (medication + PR, 5 times a week, n = 8). The 6-minute walk distance (6WMD), pulmonary function test, modified Medical Research Council dyspnea scale, COPD assessment test (CAT), and St. George Respiratory Questionnaire (SGRQ) survey were carried out before starting the trial and after 4 and 8 weeks to determine motor performance, lung function, and dyspnea.

RESULTS

After 8 weeks, the pulmonary function test scores were the same. The 6MWD (PR, 28.3 ± 38.5; LCE, 14.5 ± 53.1; SC, 11.5 ± 20.5; P = .984), modified Medical Research Council dyspnea scale (PR, 0.8 ± 1.0; LCE, 0.8 ± 0.8; SC, 0.3 ± 0.5; P = .772), CAT (PR, 7.3 ± 6.2; LCE, 4.2 ± 5.2; SC, 1.0 ± 2.2; P = .232), and SGRQ scores (PR, 11.5 ± 15.4; LCE, 5.5 ± 13.1; SC, 4.8 ± 5.1; P = .358 [PR vs LCE], P = .795 [PR vs SC]) had improved in order of PR, LCE, and SC group. Although there were no statistically significant differences in the outcome measures between the groups, there were clinically significant improvements in the CAT and SGRQ scores.

CONCLUSIONS

In this trial, PR showed more improvement in symptoms and quality of life than SC alone. To seek a more precise use of LCE, further full-sized studies with a long duration and additional outcome measures such as psychological assessment tools and cost-effectiveness ratio should be conducted.

TRIAL REGISTRATION

KCT0004724.

EFFECTS OF FARINELLI BREATHING EXERCISE ON RESPIRATORY FUNCTION AND SYMPTOMS IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Background

Farinelli breathing (FB) exercise is a typical breathing exercise used by singers. This study aimed to compare effects of FB exercise and diaphragmatic breathing (DB) exercise on respiratory function and symptoms in patients with chronic obstructive pulmonary disease (COPD).

Methods

Sixteen patients aged 51–80 years with mild or moderate COPD were recruited for this study. They were divided into two groups: DB group (n=8) and FB group (n=8). Both groups received complete breathing exercise training five times per week for 8 weeks. Their respiratory functions, COPD symptoms, cytokine levels, and oxidative stress variables were analyzed during pre- and post-tests. Dependent variables were compared between pre- and post-tests using paired t-tests. An independent t-test was used to compare variables between the groups. Differences were considered significant at p<0.05.

Results

The maximal expiratory pressure (MEP), maximum oxygen consumption (VO₂max), and COPD Assessment Test (CAT) scores changed significantly in the DB group after the 8-week intervention compared to those at pre-test, whereas force vital capacity, forced expiratory volume in the first second, maximum voluntary ventilation, maximal inspiratory pressure (MIP), MEP, VO₂max, CAT score, tumor necrosis factor-α, and malondialdehyde level changed significantly in the FB group at post-test compared to those at pre-test. Moreover, both MIP and MEP in the FB group were significantly higher than those in the DB group.

Conclusion

FB exercise improved respiratory functions and COPD symptoms of patients with COPD. It might be an alternative breathing exercise in pulmonary rehabilitation programs for patients with COPD.

Coughing and diaphragmatic breathing exercise: What is the repercussion on respiratory mechanics of children and adolescents with cystic fibrosis?

INTRODUCTION

The aim of this study was to investigate the immediate effect of coughing episodes and diaphragmatic breathing exercise (DBE) on respiratory mechanics of children/adolescents with cystic fibrosis (CF).

METHODS

It is a cross-sectional analytical study that occurred in a reference center for children with CF. Forty-five children/adolescents with CF (60% male; mean age 10.22 ± 2.84 years old; mean forced expiratory volume in 1 second 73.74 ± 21.38% predicted) were divided into 3 groups according to the R5 parameter response to the DBE: G1 (increased R5), G2 (no change R5), and G3 (decreased R5). The children/adolescents performed 5 successive coughs and 10 DBE. The main outcome measures were the impulse oscillometry system (IOS) parameters evaluated before, during, and after the interventions.

RESULTS

In the total sample, the IOS parameters (Z5, R5, and R20) were worse after coughing, and they did not change after the DBE. In the G1, the parameters were progressively worsening during the interventions. In the G2, they worsened after coughing and after the DBE. In the G3, they worsened after coughing; however, after the DBE, the IOS parameters have improved and returned close to the baseline.

CONCLUSIONS

The children/adolescents with CF airway resistance got worse after coughing episodes, and 10 DBE repetitions did not affect the respiratory mechanics in most of the sample. Meanwhile, in the group with older children, the DBE worsened the respiratory mechanics, yet in the younger group it improved.

Control of the expiratory flow in a lung model and in healthy volunteers with an adjustable flow regulator: a combined bench and randomized crossover study

Background

Pursed-lips breathing (PLB) is a technique to attenuate small airway collapse by regulating the expiratory flow. During mandatory ventilation, flow-controlled expiration (FLEX), which mimics the expiratory flow course of PLB utilizing a digital system for measurement and control, was shown to exert lung protective effects. However, PLB requires a patient’s participation and coordinated muscular effort and FLEX requires a complex technical setup. Here, we present an adjustable flow regulator to mimic PLB and FLEX, respectively, without the need of a patient’s participation, or a complex technical device.

Methods

Our study consisted of two parts: First, in a lung model which was ventilated with standard settings (tidal volume 500 ml, respiratory rate 12 min⁻¹, positive end-expiratory pressure (PEEP) 5 cmH₂O), the possible reduction of the maximal expiratory flow by utilizing the flow regulator was assessed. Second, with spontaneously breathing healthy volunteers, the short-term effects of medium and strong expiratory flow reduction on airway pressure, the change of end-expiratory lung volume (EELV), and breathing discomfort was investigated.

Results

In the lung model experiments, expiratory flow could be reduced from − 899 ± 9 ml·s⁻¹ down to − 328 ± 25 ml·s⁻¹. Thereby, inspiratory variables and PEEP were unaffected. In the volunteers, the maximal expiratory flow of − 574 ± 131 ml·s⁻¹ under baseline conditions was reduced to − 395 ± 71 ml·s⁻¹ for medium flow regulation and to − 266 ± 58 ml·s⁻¹ for strong flow regulation, respectively (p < 0.001). Accordingly, mean airway pressure increased from 0.6 ± 0.1 cmH₂O to 2.9 ± 0.4 cmH₂O with medium flow regulation and to 5.4 ± 2.4 cmH₂O with strong flow regulation, respectively (p < 0.001). The EELV increased from baseline by 31 ± 458 ml for medium flow regulation and 320 ± 681 ml for strong flow regulation (p = 0.033). The participants rated breathing with the flow regulator as moderately uncomfortable, but none rated breathing with the flow regulator as intolerable.

Conclusions

The flow regulator represents an adjustable device for application of a self-regulated expiratory resistive load, representing an alternative for PLB and FLEX. Future applications in spontaneously breathing patients and patients with mandatory ventilation alike may reveal potential benefits.

Trial registration: DRKS00015296, registered on 20th August, 2018; URL: https://www.drks.de/drks_web/setLocale_EN.do.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01886-7.

Role of rehabilitation amidst the COVID-19 pandemic: a review

COVID-19 remains globally a highly infectious disease targeting multiple organs. Rehabilitation is increasingly valued among the supportive care fields to combat COVID-19 as currently definitive curative treatment remains largely absent. This narrative review is to address rehabilitation related topics associated with the treatment of COVID-19 patients. Nosocomial spread remains a high risk for healthcare workers, with comparable high ratios of exposed workers suffering from the disease with more severe clinical course. Primary principle of rehabilitation is to protect rehabilitation physicians and cover all person-to-person interactions. Translating perspectives are encouraged through each multidisciplinary approach. Rehabilitation for the outpatient remains a potential beneficial approach. Artificial intelligence can potentially provide aid and possible answers to important problems that may emerge involving COVID-19. The real value of rehabilitation in COVID-19 may be very impactful and beneficial for patient's physical and mental health.

Novel Real-Time OEP Phase Angle Feedback System for Dysfunctional Breathing Pattern Training-An Acute Intervention Study

Dysfunctional breathing patterns (DBP) can have an impact on an individual’s quality of life and/or exercise performance. Breathing retraining is considered to be the first line of treatment to correct breathing pattern, for example, reducing ribcage versus abdominal movement asynchrony. Optoelectronic plethysmography (OEP) is a non-invasive 3D motion capture technique that measures the movement of the chest wall. The purpose of this study was to investigate if the use of a newly developed real-time OEP phase angle and volume feedback system, as an acute breathing retraining intervention, could result in a greater reduction of phase angle values (i.e., an improvement in movement synchrony) when compared to real-time OEP volume feedback alone. Eighteen individuals with a DBP performed an incremental cycle test with OEP measuring chest wall movement. Participants were randomly assigned to either the control group, which included the volume-based OEP feedback or to the experimental group, which included both the volume-based and phase angle OEP feedback. Participants then repeated the same cycle test using the real-time OEP feedback. The phase angle between the ribcage versus abdomen (RcAbPhase), between the pulmonary ribcage and the combined abdominal ribcage and abdomen (RCpAbPhase), and between the abdomen and the shoulders (AbSPhase) were calculated during both cycle tests. Significant increases in RcAbPhase (pre: −2.89°, post: −1.39°, p < 0.01), RCpAbPhase (pre: −2.00°, post: −0.50°, p < 0.01), and AbSPhase (pre: −2.60°, post: −0.72°, p < 0.01) were found post-intervention in the experimental group. This indicates that the experimental group demonstrated improved synchrony in their breathing pattern and therefore, reverting towards a healthy breathing pattern. This study shows for the first time that dysfunctional breathing patterns can be acutely improved with real-time OEP phase angle feedback and provides interesting insight into the feasibility of using this novel feedback system for breathing pattern retraining in individuals with DBP.

Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19

This analysis extrapolates information from previous studies and experiences to bring physical medicine and rehabilitation perspective and intervention to the multidisciplinary treatment of COVID-19. The purpose of pulmonary rehabilitation in COVID-19 patients is to improve symptoms of dyspnea, relieve anxiety, reduce complications, minimize disability, preserve function, and improve quality of life. Pulmonary rehabilitation during the acute management of COVID-19 should be considered when possible and safe and may include nutrition, airway, posture, clearance technique, oxygen supplementation, breathing exercises, stretching, manual therapy, and physical activity. Given the possibility of long-term disability, outpatient posthospitalization pulmonary rehabilitation may be considered in all patients hospitalized with COVID-19.

The effect of lung-conduction exercise in chronic obstructive pulmonary disease: Study protocol for randomized, assessor-blind, multicenter trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is an irreversible disease characterized by cough, sputum production, and dyspnea, and has a high prevalence and mortality. Pulmonary rehabilitation (PR) is a management that improves the quality of life for COPD patients; however, PR is not readily accessible. Therefore, we developed lung-conduction exercises (LCE) that can be performed without any limitations. LCE consists of breathing, stretching, and tapping to relieve dyspnea in COPD patients.

METHODS/DESIGN

This randomized, assessor-blind, multicenter trial aims to recruit 54 patients with moderate and severe COPD. Subjects will be randomly allocated to a control group (only medication), an LCE group (medication + LCE, 5 times a week), or a PR group (medication + PR, 5 times a week). The 6-minute walk distance, pulmonary function tests (forced expiratory volume at 1 second, forced vital capacity, and forced expiratory volume at 1 second/forced vital capacity), modified Borg scale, modified medical research council dyspnea scale, COPD assessment test, and St. George respiratory questionnaire will be measured before starting the trial and after the 4th and 8th weeks to determine motor performance, lung function, and dyspnea.

CONCLUSION

We aim to demonstrate that LCE is effective in improving symptoms and psychosomatic stability in COPD patients. Therefore, this trial will play an important role in fortifying the foundation of clinical application.

A randomized controlled trial on inspiratory muscle training in pulmonary hypertension: Effects on respiratory functions, functional exercise capacity, physical activity, and quality of life

BACKGROUND

Impaired respiratory muscle function may be one of the causes of increased dyspnea, reduced exercise capacity, and physical activity (PA), and poor quality of life in pulmonary hypertension (PH).

OBJECTIVE

To investigate the effects of threshold inspiratory muscle training (TIMT) on respiratory functions, functional exercise capacity, PA, and QoL in patients with PH.

METHODS

Thirty patients with PH were randomly allocated to a TIMT (n = 15) and sham group (n = 15). Three patients in the sham group could not participate in the program. The TIMT group (n = 15) trained at 30% of the maximal inspiratory pressure (MIP), and the sham group (n = 12) performed at lowest pressure without change in threshold pressure. In both groups, patients performed TIMT at home for 15 min, twice per day, with the MIP load determined by the trainer, and were supervised once weekly at the hospital for eight weeks. The primary outcomes were MIP and maximal expiratory pressure (MEP). The secondary outcome measures included spirometric measurements, six-minute walking distance (6MWD), PA (SenseWear armband and International Physical Activity Questionnaire-Short Form-IPAQ-Short Form), and QoL (Minnesota Living with Heart Failure-MLHF).

RESULTS

After the training, changes in MIP (p = 0.023) were higher in the intervention group compared with the sham group. Differences in MEP, FEV1 (%), FVC (%), FEV1/FVC (%), 6MWD, %6MWD, IPAQ-SF, MLHFQ, and armband parameters were not significantly different between the groups (p > 0.05).

CONCLUSIONS

The results of the study demonstrated that TIMT could increase MIP and did not improve other parameters of respiratory functions, functional exercise capacity, PA, and QoL in patients with PH.

Novel versus Traditional Inspiratory Muscle Training Regimens as Home-Based, Stand-Alone Therapies in COPD: Protocol for a Randomized Controlled Trial

BACKGROUND

Subjects with COPD frequently develop considerable weakness and deconditioning of the inspiratory musculature, which can be corrected with inspiratory muscle training (IMT). While rehabilitation centers may be able to provide IMT as part of the rather complex management of COPD, there is currently a lack of rehabilitation services in the Czech Republic. Remote IMT may then benefit subjects with COPD who are unable to attend or do not have access to rehabilitation programs. We aim at evaluating the utility of the test of incremental respiratory endurance (TIRE) as an at-home IMT method in subjects with COPD, while comparing the effectiveness of this novel training approach to the outcomes of traditional, threshold loading IMT protocols.

METHODS/DESIGN

This prospective, randomized controlled trial will comprise 8 weeks of at-home IMT sessions with remote supervision followed by 4 months of unsupervised, independent IMT. Eligible subjects will be randomly assigned to one of the following three distinct home-based IMT protocols: (1) TIRE, (2) Threshold loading, and (3) Sham training. Subjects allocated to the TIRE group will train once daily using an advanced IMT electronic system (PrO2), while the other two groups will receive threshold devices. Study outcomes will include measures of inspiratory muscle strength and endurance, pulmonary function, COPD-specific symptomatology, functional exercise capacity, surrogate markers of mortality risk, mental health status and health-related quality of life.

DISCUSSION

While we acknowledge the value of threshold loading IMT protocols, we believe that the TIRE training method has the potential to provide additional clinical benefits in COPD given its sophisticated remote tracking system and ability to modulate all aspects of muscular performance, including not only strength but also endurance, power and work capacity, allowing users to achieve considerably higher inspiratory pressures throughout the full range of inspiration when compared to other more traditionally used IMT methods.

Improvements of Shooting Performance in Adolescent Air Rifle Athletes After 6-Week Balance and Respiration Training Programs

CONTEXT

Several factors, such as balance and respiration training programs, have been identified as contributing to a shooting performance. However, little is known about the benefits of these programs on the shooting records of adolescent air rifle athletes.

OBJECTIVE

The purpose of this study was to investigate whether balance and respiration training can contribute to the shooting performance required for adolescent air rifle shooting athletes.

DESIGN

Case-control study.

SETTING

Shooting range.

PARTICIPANTS

A total of 21 adolescent air rifle athletes were recruited from the local school community and assigned to an experimental (n = 11; EG) or control (n = 10; CG) group.

INTERVENTION

The EG performed respiration and balance training for 30 minutes 3 times a week for 6 weeks, and the CG performed balance training only.

MAIN OUTCOME MEASURES

Data were collected on the respiratory function, muscle activity, and shooting record before and after the 6-week intervention.

RESULTS

The forced vital capacity (FVC), forced expired volume in 1 second (FEV1), FEV1 as a percentage of FVC, peak expiratory flow, and maximum voluntary ventilation were significantly increased in the EG, and FEV1 as a percentage of FVC was significantly increased in the CG (P < .05). The FVC and peak expiratory flow postintervention were significantly different between the groups (P < .05). The activity of the right internal oblique (IO) and left IO muscles of the FVC were significantly different in the EG (P < .05). Within-group changes in right external oblique, right IO, and left IO of the maximum voluntary ventilation were significantly increased in the EG (P < .05). The right IO and left IO activity improved more significantly in the EG than CG (P < .05). There was no difference between the groups with respect to the shooting records.

CONCLUSIONS

The clinical significance of this study is the balance and respiration training affected the respiration function capacity and muscle activity, but did not affect the shooting record. Nevertheless, these training are a potential approach method to improve athletes' shooting record.

The BODE index and inspiratory muscle performance in COPD: Clinical findings and implications

Objectives

The Test of Incremental Respiratory Endurance is a novel testing method that provides a unique examination of one's inspiratory muscle strength, work and endurance. Little is known about the relationship between inspiratory muscle performance and mortality risk in obstructive lung disease. We examined the relationship between the Test of Incremental Respiratory Endurance measures and the Body-mass index, airflow Obstruction, Dyspnea and Exercise index in chronic obstructive pulmonary disease.

Methods

In all, 70 males with mild-to-very severe chronic obstructive pulmonary disease (mean ± standard deviation of 70.2 ± 5.9 years) underwent measurements of body-mass index, spirometry, dyspnea and a 6-min walk test from which the Body-mass index, airflow Obstruction, Dyspnea and Exercise score was calculated. The Test of Incremental Respiratory Endurance provided measures of maximal inspiratory pressure, sustained maximal inspiratory pressure and inspiratory duration.

Results

All Test of Incremental Respiratory Endurance parameters inversely correlated with the Body-mass index, airflow Obstruction, Dyspnea and Exercise score: maximal inspiratory pressure (r = -0.355, p = 0.00), sustained maximal inspiratory pressure (r = -0.426, p = 0.00) and ID (r = -0.278, p = 0.02), with sustained maximal inspiratory pressure displaying the highest correlation. Independent significant correlations were also observed between the sustained maximal inspiratory pressure and all Body-mass index, airflow Obstruction, Dyspnea and Exercise score components, except for body-mass index. Finally, sustained maximal inspiratory pressure was significantly different among the Body-mass index, airflow Obstruction, Dyspnea and Exercise index quartiles.

Discussion

The significant association between the Body-mass index, airflow Obstruction, Dyspnea and Exercise score and inspiratory muscle performance, in particular sustained maximal inspiratory pressure, suggests that these measures may have a potential prognostic value in the evaluation of chronic obstructive pulmonary disease.

Reliability and validity of the test of incremental respiratory endurance measures of inspiratory muscle performance in COPD

Purpose

The Test of Incremental Respiratory Endurance (TIRE) provides a comprehensive assessment of inspiratory muscle performance by measuring maximal inspiratory pressure (MIP) over time. The integration of MIP over inspiratory duration (ID) provides the sustained maximal inspiratory pressure (SMIP). Evidence on the reliability and validity of these measurements in COPD is not currently available. Therefore, we assessed the reliability, responsiveness and construct validity of the TIRE measures of inspiratory muscle performance in subjects with COPD.

Patients and methods

Test-retest reliability, known-groups and convergent validity assessments were implemented simultaneously in 81 male subjects with mild to very severe COPD. TIRE measures were obtained using the portable PrO2 device, following standard guidelines.

Results

All TIRE measures were found to be highly reliable, with SMIP demonstrating the strongest test-retest reliability with a nearly perfect intraclass correlation coefficient (ICC) of 0.99, while MIP and ID clustered closely together behind SMIP with ICC values of about 0.97. Our findings also demonstrated known-groups validity of all TIRE measures, with SMIP and ID yielding larger effect sizes when compared to MIP in distinguishing between subjects of different COPD status. Finally, our analyses confirmed convergent validity for both SMIP and ID, but not MIP.

Conclusion

The TIRE measures of MIP, SMIP and ID have excellent test-retest reliability and demonstrated known-groups validity in subjects with COPD. SMIP and ID also demonstrated evidence of moderate convergent validity and appear to be more stable measures in this patient population than the traditional MIP.

Singing for adults with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Singing is a complex physical activity dependent on the use of the lungs for air supply to regulate airflow and create large lung volumes. In singing, exhalation is active and requires active diaphragm contraction and good posture. Chronic obstructive pulmonary disease (COPD) is a progressive, chronic lung disease characterised by airflow obstruction. Singing is an activity with potential to improve health outcomes in people with COPD.

OBJECTIVES

To determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

SEARCH METHODS

We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, the World Health Organization trials portal and PEDro, from their inception to August 2017. We also reviewed reference lists of all primary studies and review articles for additional references.

SELECTION CRITERIA

We included randomised controlled trials in people with stable COPD, in which structured supervised singing training of at least four sessions over four weeks' total duration was performed. The singing could be performed individually or as part of a group (choir) facilitated by a singing leader. Studies were included if they compared: 1) singing versus no intervention (usual care) or another control intervention; or 2) singing plus pulmonary rehabilitation versus pulmonary rehabilitation alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected trials for inclusion, extracted outcome data and assessed risk of bias. We contacted authors of trials for missing data. We calculated mean differences (MDs) using a random-effects model. We were only able to analyse data for the comparison of singing versus no intervention or a control group.

MAIN RESULTS

Three studies (a total of 112 participants) were included. All studies randomised participants to a singing group or a control group. The comparison groups included a film workshop, handcraft work, and no intervention. The frequency of the singing intervention in the studies ranged from 1 to 2 times a week over a 6 to 24 week period. The duration of each singing session was 60 minutes.All studies included participants diagnosed with COPD with a mean age ranging from 67 to 72 years and a mean forced expiratory volume in one second (FEV₁) ranging from 37% to 64% of predicted values. The sample size of included studies was small (33 to 43 participants) and overall study quality was low to very low. Blinding of personnel and participants was not possible due to the physical nature of the intervention, and selection and reporting bias was present in two studies.For the primary outcome of health-related quality of life, there was no statistically significant improvement in the St George's Respiratory Questionnaire total score (mean difference (MD) -0.82, 95% confidence interval (CI) -4.67 to 3.02, 2 studies, n = 58, low-quality evidence). However, there was a statistically significant improvement in the SF-36 Physical Component Summary (PCS) score favouring the singing group (MD 12.64, 95% CI 5.50 to 19.77, 2 studies, n = 52, low-quality evidence). Only one study reported results for the other primary outcome of dyspnoea, in which the mean improvement in Baseline Dyspnoea Index (BDI) score favouring the singing group was not statistically significant (MD 0.40, 95% CI -0.65 to 1.45, 1 study, n = 30, very low-quality evidence).No studies examined any long-term outcomes and no adverse events or side effects were reported.

AUTHORS' CONCLUSIONS

There is low to very low-quality evidence that singing is safe for people with COPD and improves physical health (as measured by the SF-36 physical component score), but not dyspnoea or respiratory-specific quality of life. The evidence is limited due to the low number of studies and the small sample size of each study. No evidence exists examining the long-term effect of singing for people with COPD. The absence of studies examining singing performed in conjunction with pulmonary rehabilitation precludes the formulation of conclusions about the effects of singing in this context. More randomised controlled trials with larger sample sizes and long-term follow-up, and trials examining the effect of singing in addition to pulmonary rehabilitation, are required to determine the effect of singing on health-related quality of life and dyspnoea in people with COPD.

Clinical and Physiological Effects of Rollators in Individuals With Chronic Obstructive Pulmonary Disease: A SYSTEMATIC REVIEW

PURPOSE

To determine the effects of using a rollator in people with chronic obstructive pulmonary disease (COPD).

METHODS

Studies were systematically identified from literature searches of MEDLINE, CINAHL, PEDro, PubMed, EMBASE, and the Cochrane Library databases and the reference lists of included studies. Two reviewers independently selected randomized controlled or crossover studies examining the effects of rollator usage compared with no aid in individuals with COPD. Methodologic quality was assessed by 2 reviewers independently using the Cochrane Risk of Bias tool. Two reviewers also used a customized form to extract characteristics of and outcomes for subjects related to exercise capacity, symptoms, health-related quality of life (HRQOL), physiological, and gait parameters. Weighted mean differences (WMD) with 95% CI were calculated using a fixed-effects model.

RESULTS

A total of 7 studies (126 participants) were included. Use of a rollator during a 6-Minute Walk Test (6MWT) improved distance walked (WMD = 13 m; 95% CI, 5-22) and lowered end-6MWT dyspnea rating (WMD = 0.97; 95% CI, 0.63-1.32). Longer-term use did not appear to impact exercise capacity or HRQOL, although this may be related to the frequency of use.

CONCLUSIONS

When used in the short-term, rollators resulted in a small increase in 6MWT and a reduction in dyspnea. Details on patient adherence are required to accurately evaluate the longer-term effects of rollator usage.

The impact of breathing pattern and rate on inspiratory muscles activity

Different rehabilitation programs are used to relieve dyspnea for hyper-inflated lung patients. In this study, a new approach, based on integrated changes in respiratory rate and pattern, for inspiratory muscles rehabilitation and training was examined utilizing noninvasive measurements of the two inspiratory muscles (rib cage inspiratory and neck inspiratory muscles) activity during controlled breathing in healthy subjects. Muscles activity was measured using electromyography, while subjects, breathed at different combinations of respiratory rate (6, 10, 16 breath per minutes) and inspiratory duty cycles (TI/Ttot). The results clearly show that both muscles were most active at the lowest evaluated respiratory rate, and that alteration of the duty cycle at the lowest rate significantly (p< 0.05) changes their electrical activity. Breathing at low respiratory rate RR is recommended for hyper-inflated lung patients in order to improve their gas exchange, therefore, it is recommended for these patients to find their most effective combination of RR and TI/Ttot and to use control breathing to practice their breath at optimum combination.

Dysfunctional breathing: a review of the literature and proposal for classification

Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in excess of the magnitude of physiological respiratory or cardiac disease. We reviewed the literature and propose a classification system for the common dysfunctional breathing patterns described. The literature was searched using the terms: dysfunctional breathing, hyperventilation, Nijmegen questionnaire and thoraco-abdominal asynchrony. We have summarised the presentation, assessment and treatment of dysfunctional breathing, and propose that the following system be used for classification. 1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia. 2) Periodic deep sighing: frequent sighing with an irregular breathing pattern. 3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea. 4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration. 5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.

This review highlights the common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing. Future work should aim to further investigate the prevalence, clinical associations and treatment of these presentations.

The effect of positioning and diaphragmatic breathing exercises on respiratory muscle activity in people with chronic obstructive pulmonary disease

BACKGROUND

Body positioning and diaphragmatic breathing may alter respiratory pattern and reduce dyspnoea in people with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To determine the effect of positioning and diaphragmatic breathing on respiratory muscle activity in a convenience sample of people with COPD, using surface electromyography (sEMG).

METHODS

This prospective descriptive study recorded sEMG measurements at baseline, after upright positioning, during diaphragmatic breathing and 5 minutes thereafter. Vital signs and levels of perceived dyspnoea were recorded at baseline and at the end of the study. Data were analysed using repeated measures ANOVAs with post hoc t-tests for dependent and independent variables.

RESULTS

Eighteen participants (13 male; mean ± standard deviation age 59.0 ± 7.9 years) were enrolled. Total diaphragmatic activity did not change with repositioning (p = 0.2), but activity increased from 7.3 ± 4.2 µV at baseline to 10.0 ± 3.3 µV during diaphragmatic breathing (p = 0.006) with a subsequent reduction from baseline to 6.1 ± 3.5 µV (p = 0.007) at the final measurement. There was no change in intercostal muscle activity at different time points (p = 0.8). No adverse events occurred. Nutritional status significantly affected diaphragmatic activity (p = 0.004), with participants with normal body mass index (BMI) showing the greatest response to both positioning and diaphragmatic breathing. There were no significant changes in vital signs, except for a reduction in systolic/diastolic blood pressure from 139.6 ± 18.7/80.4 ± 13.0 to 126.0 ± 15.1/75.2 ± 14.7 (p < 0.05).

CONCLUSION

A single session of diaphragmatic breathing transiently improved diaphragmatic muscle activity, with no associated reduction in dyspnoea.

Influence of torso and arm positions on chest examinations by electrical impedance tomography

Electrical impedance tomography (EIT) is increasingly used in patients suffering from respiratory disorders during pulmonary function testing (PFT). The EIT chest examinations often take place simultaneously to conventional PFT during which the patients involuntarily move in order to facilitate their breathing. Since the influence of torso and arm movements on EIT chest examinations is unknown, we studied this effect in 13 healthy subjects (37  ±  4 years, mean age  ±  SD) and 15 patients with obstructive lung diseases (72  ±  8 years) during stable tidal breathing. We carried out the examinations in an upright sitting position with both arms adducted, in a leaning forward position and in an upright sitting position with consecutive right and left arm elevations. We analysed the differences in EIT-derived regional end-expiratory impedance values, tidal impedance variations and their spatial distributions during all successive study phases. Both the torso and the arm movements had a highly significant influence on the end-expiratory impedance values in the healthy subjects (p  =  0.0054 and p  <  0.0001, respectively) and the patients (p  <  0.0001 in both cases). The global tidal impedance variation was affected by the torso, but not the arm movements in both study groups (p  =  0.0447 and p  =  0.0418, respectively). The spatial heterogeneity of the tidal ventilation distribution was slightly influenced by the alteration of the torso position only in the patients (p  =  0.0391). The arm movements did not impact the ventilation distribution in either study group. In summary, the forward torso movement and the arms' abduction exert significant effects on the EIT waveforms during tidal breathing. We recommend strict adherence to the upright sitting position during PFT when EIT is used.

Inspiratory Muscle Training in Late-Onset Pompe Disease: The Effects on Pulmonary Function Tests, Quality of Life, and Sleep Quality

INTRODUCTION

Late-onset Pompe disease (LOPD) is characterized by progressive skeletal and respiratory muscle weakness. Little is known about the effect of inspiratory muscle training (IMT) on pulmonary function in subjects with LOPD. The aim of the present study was to investigate the effect of an 8-week IMT program on pulmonary function tests, quality of life, and sleep quality in eight patients with LOPD who were receiving enzyme replacement therapy (ERT).

METHODS

Before and after the IMT program, spirometric measurements in sitting and supine positions, and measurements of maximum inspiratory and expiratory pressures, peak cough flow, quality of life (assessed using the Nottingham Health Profile), and sleep quality (assessed using the Pittsburgh sleep quality index) were performed.

RESULTS

A significant increase in maximum inspiratory pressure (cmH2O and % predicted) (median [interquartile range]: 30.0 cmH2O [21.5-48] versus 39 cmH2O [31.2-56.5] and 38.3 % [28.1-48.4] versus 50.5 % [37.7-54.9]) was observed after training (p = 0.01). There were no significant changes in the other pulmonary function measurements. With the exception of the social isolation subscore (p = 0.02), quality of life subscores did not change after IMT (p > 0.05). Sleep quality subscores and total scores were similar before and after IMT.

CONCLUSION

These results suggest that IMT has a positive effect on maximum inspiratory pressure in subjects with LOPD who are under ERT.

Long-term Exercise After Pulmonary Rehabilitation (LEAP): Design and rationale of a randomized controlled trial of Tai Chi

BACKGROUND

Persons with chronic obstructive pulmonary disease (COPD) have reduced exercise capacity and levels of physical activity. Supervised, facility-based pulmonary rehabilitation programs improve exercise capacity and reduce dyspnea, but novel long-term strategies are needed to maintain the benefits gained. Mind-body modalities such as Tai Chi which combine aerobic activity, coordination of breathing, and cognitive techniques that alleviate the physical inactivity, dyspnea, and anxiety and depression that are the hallmarks of COPD are promising strategies.

METHODS/DESIGN

We have designed a randomized controlled study to examine whether Tai Chi will maintain exercise capacity in persons with COPD who have recently completed a supervised pulmonary rehabilitation program, compared to standard care. The primary outcome is 6-min walk test distance at 6 months. Secondary outcomes include health-related quality of life, dyspnea, mood, occurrence of acute exacerbations, engagement in physical activity, exercise self-efficacy, and exercise adherence. Simultaneously, we are conducting a pilot study of group walking. We will enroll 90 persons who will be randomized to one of three arms in a 2:2:1 ratio: Tai Chi, standard care, or group-based walking.

DISCUSSION

The Long-term Exercise After Pulmonary Rehabilitation (LEAP) study is a novel and clinically relevant trial. We will enroll a well-characterized cohort of persons with COPD and will comprehensively assess physiological and psychosocial outcomes. Results of this study will provide the evidence base for persons with COPD to engage in Tai Chi as a low-cost, long-term modality to sustain physical activity in persons who have completed a standard short-term pulmonary rehabilitation program.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, with the ID number of NCT01998724.

Real-time 3D visualization of the thoraco-abdominal surface during breathing with body movement and deformation extraction

Real-time 3D visualization of the breathing displacements can be a useful diagnostic tool in order to immediately observe the most active regions on the thoraco-abdominal surface. The developed method is capable of separating non-relevant torso movement and deformations from the deformations that are solely related to breathing. This makes it possible to visualize only the breathing displacements. The system is based on the structured laser triangulation principle, with simultaneous spatial and color data acquisition of the thoraco-abdominal region. Based on the tracking of the attached passive markers, the torso movement and deformation is compensated using rigid and non-rigid transformation models on the three-dimensional (3D) data. The total time of 3D data processing together with visualization equals 20 ms per cycle.In vitro verification of the rigid movement extraction was performed using the iterative closest point algorithm as a reference. Furthermore, a volumetric evaluation on a live subject was performed to establish the accuracy of the rigid and non-rigid model. The root mean square deviation between the measured and the reference volumes shows an error of  ±0.08 dm(3) for rigid movement extraction. Similarly, the error was calculated to be  ±0.02 dm(3) for torsional deformation extraction and  ±0.11 dm(3) for lateral bending deformation extraction. The results confirm that during the torso movement and deformation, the proposed method is sufficiently accurate to visualize only the displacements related to breathing. The method can be used, for example, during the breathing exercise on an indoor bicycle or a treadmill.

Differences in respiratory muscle activity during cycling and walking do not influence dyspnea perception in obese patients with COPD

In patients with combined obesity and chronic obstructive pulmonary disease (COPD), dyspnea intensity at matched work rates during weight-supported cycling and weight-bearing walking is similar, despite consistent metabolic differences between test modalities. The present study examined the influence of differences in activity of the diaphragm and abdominal muscles during cycling and walking on intensity and quality of dyspnea at matched ventilation in obese patients with COPD. We compared respiratory muscle activity patterns and dyspnea ratings during incremental cycle and treadmill exercise tests, where work rate was matched, in 12 obese (body mass index 36.6 ± 5.4 kg/m2; mean ± SD) patients with moderate COPD. We used a multipair electrode-balloon catheter to compare electromyography of the diaphragm and esophageal, gastric, and transdiaphragmatic pressures during the two exercise tests. Ventilation, breathing pattern, operating lung volumes, global respiratory effort, and electrical activation of the diaphragm were similar across exercise modalities for a given work rate. The cycling position was associated with greater neuromuscular efficiency of the diaphragm ( P < 0.01), greater diaphragm use ( P < 0.01) measured by the ventilatory muscle recruitment index, and less expiratory muscle activity compared ( P < 0.01) with treadmill walking. However, intensity and quality of dyspnea were similar between exercise modalities. In obese patients with COPD, altered respiratory muscle activity due to body position differences between cycling and walking did not modulate perceived dyspnea when indirect measures of respiratory neural drive were unchanged.

Effects of controlled breathing exercises and respiratory muscle training in people with chronic obstructive pulmonary disease: results from evaluating the quality of evidence in systematic reviews

Background

This paper reviews evidence and quality of Systematic Reviews (SRs) on the effects of breathing control exercises (BCEs) and respiratory muscle training (RMT) on breathlessness/dyspnea and other symptoms, and quality of life (QOL) for individuals with chronic obstructive pulmonary disease (COPD).

Methods

A search for BCE and RMT literature in COPD published between January 1, 2002 and December 31, 2013 was performed in the following databases: PubMed, Ovid, CINAHL, PsycINFO, AMED, Cochrane and PEDro. The AMSTAR criteria were used to evaluate quality.

Results

After reviewing 642 reports, seven SRs were identified on RMT and BCEs. Three SRs were of high quality, three were of moderate quality, and one was of low quality. Two high-quality SRs reported significantly beneficial effects of RMT on dyspnea, and one reported significant effects on disease-specific QOL and fatigue. In these SRs, pooled data analyses were performed with three to fourteen single randomised control trials (RCTs) included in the analysis. In one of the SRs the quality of the single RCTs were rated by the authors to be between 5–7 (with10 best) and in the other one the quality of the single RCTs were rated to be between 30-83% of the maximum score.

One high-quality SR found a significant positive effect of BCE based on pooled data analysis with two single RCTs in regard to pursed-lip breathing (PLB) on breathlessness. In this SR, one single RCT on diaphragmatic breathing (DB) and another one on yoga breathing (YB) showed effect on disease-specific QOL. The single RCTs included in the SR were rated by the authors in the SRs to be of low and moderate quality.

Conclusions

Based on three high-quality SRs performing pooled data analyses, there is evidence that RMT has effect on breathlessness, fatigue and disease-specific QOL and PLB on breathlessness. There is also evidence that single studies on DB and YB has effect on disease-specific QOL. Few RCTs are available and the variable quality of the single RCTs in the SRs, seem to require more RCTs in particular for BCEs, but also RMT before conclusions regarding effects and high quality SRs can be written.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2466-14-184) contains supplementary material, which is available to authorized users.

Tai chi mind-body exercise in patients with COPD: study protocol for a randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic, progressively debilitating condition that is prevalent in the US and worldwide. Patients suffer from progressive dyspnea and exercise intolerance. Physical exercise is beneficial, but conventional pulmonary rehabilitation programs are underutilized. There remains a need for novel interventions that improve symptoms, quality-of-life, and functional capacity. Tai chi is an increasingly popular mind-body exercise that includes physical exercise, breathing training, mindful awareness, and stress management--components that are essential to the self-management of COPD. There are, however, limited data on the effectiveness of tai chi as a therapeutic intervention in this population.

METHODS/DESIGN

The Primary Aims are to evaluate the efficacy, safety, and feasibility of a 12-week tai chi program for patients with COPD. We utilize a randomized controlled trial design, with participants assigned in a 2:1 ratio to either a group tai chi program (N = 63) or a time/attention-matched education control (N = 31). Our primary outcomes are COPD-specific quality-of-life and exercise capacity. Secondary outcomes include dyspnea, mood, functional status, self-efficacy, and lung function. Cardiopulmonary exercise testing is done in a subset of patients (N = 50). To explore optimal training duration, a subgroup of patients in tai chi are randomly assigned to complete an additional 12 weeks training (total 24 weeks) (Exploratory Aim 1). To explore the impact of a simplified seated intervention including only a subset of tai chi's training components, a third randomly assigned group (N = 31) receives a 12- week mind-body breathing program (N = 31) (Exploratory Aim 2).

DISCUSSION

Results of the BEAM study (Breathing, Education, Awareness, Movement) will provide preliminary evidence regarding the value of tai chi for improving quality of life and exercise capacity in patients with COPD, including information regarding optimal duration. They will also inform the feasibility and potential benefit of an alternative mind-body breathing intervention, and provide insight regarding how isolated mind-body exercise components contribute to the overall effects of tai chi. Should the results be positive, tai chi and related mind-body practices may offer a novel exercise option that is potentially accessible to a large proportion of patients with COPD.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, ID number NCT01551953. Date of Registration March 1 2012.

Influence of posture on the ventilatory pattern and the thoraco-abdominal kinematics of patients with chronic obstructive pulmonary disease (COPD)

OBJECTIVE

Evaluate the influence of posture on ventilatory pattern, compartmental distribution of volume of chest wall and thoraco-abdominal kinematics of patients with severe chronic obstructive pulmonary disease (COPD).

DESIGN

Cross-sectional study.

METHODS

Twelve, male patients with severe COPD (Forced Expiratory Volume in the first second (FEV1) = 24.35 ± 4.52%, Forced Vital Capacity% (FVC%) = 60 ± 13.39% and relationship FEV1/FVC = 53.42 ± 14.47). The distribution of the volume of the ribcage [pulmonary rib cage (Rcp), abdominal ribcage (Rca) and abdomen (Ab)] during quiet breathing in a sitting position without back support (SWB), sitting with backrest (SB) and supine position (SUP) was determined using an opto-electronic plethysmograph.

RESULTS

The following differences were observed: a greater tidal volume in the SWB position when compared to the SB position (p = 0.01); greater expiratory time in the SUP position in relation to the SWB (p = 0.03) and SB (p = 0.01); and increased abdominal contribution to the tidal volume in the SUP position in relation to the SWB (p < 0.01) and SB (p < 0.001). No difference was found in the thoraco-abdominal synchrony among the positions.

CONCLUSION

Sitting position without back support enhances the activation of respiratory muscles by increasing the tidal volume and supine position seems to favor lung deflation by increasing the expiratory time. It seems appropriate to adopt these positions to optimize the ventilation/perfusion relationship and physiotherapeutic intervention in different clinical conditions.

Impact of physiotherapy on patients with advanced lung cancer

Patients with lung cancer have high mortality and high morbidity. Lung cancer-related symptoms and problems such as dyspnea, fatigue, pain, and cachexia that begin in the early phase later result in poor physical functioning, psychosocial, and quality of life status. In addition, advancing age is associated with significant comorbidity. These patients may benefit from multidisciplinary therapy to reduce the perceived severity of dyspnea and fatigue and increase physical functioning and quality of life. Based on management of symptoms and problems such as dyspnea, physical inactivity, cancer-related fatigue, respiratory secretions, pain, and anxiety–depression of these patients, it is thought that physiotherapy techniques can be used on advanced lung cancer patients following a comprehensive evaluation. However, well-designed, prospective, and randomized-controlled trials are needed to prove the efficacy of physiotherapy and pulmonary rehabilitation in general for patients with advanced lung cancer.

Effects of breathing maneuver and sitting posture on muscle activity in inspiratory accessory muscles in patients with chronic obstructive pulmonary disease

Background

To determine the influence of breathing maneuver and sitting posture on tidal volume (TV), respiratory rate (RR), and muscle activity of the inspiratory accessory muscles in patients with chronic obstructive pulmonary disease (COPD).

Methods

Twelve men with COPD participated in the study. Inductive respiratory plethysmography and surface electromyography were used to simultaneously measure TV, RR, and muscle activity of the inspiratory accessory muscles [the scalenus (SM), sternocleidomastoid (SCM), and pectoralis major (PM) muscles] during quiet natural breathing (QB) and pursed-lips breathing (PLB) in three sitting postures: neutral position (NP), with armm support (WAS), and with arm and head support (WAHS).

Results

Two-way repeated-measures analysis of variance was employed. In a comparison of breathing patterns, PLB significantly increased TV and decreased RR compared to QB. Muscle activity in the SM and SCM increased significantly in PLB compared to QB. In a comparison of sitting postures, the muscle activity of the SM, SCM, and PM increased in the forward-leaning position.

Conclusions

The results suggest that in COPD, PLB induced a favorable breathing pattern (increased TV and reduced RR) compared to QB. Additionally, WAS and WAHS positions increased muscle activity of the inspiratory accessory muscles during inspiration versus NP. Differential involvement of accessory respiratory muscles can be readily studied in COPD patients, allowing monitoring of respiratory load during pulmonary rehabilitation.

Efficacy of diaphragmatic breathing in patients with chronic obstructive pulmonary disease

This study investigated the effects of diaphragmatic breathing (DB) on ventilation and breathing pattern, seeking to identify predictors of its efficacy in patients with chronic obstructive pulmonary disease (COPD). Twenty-nine patients with moderate and severe COPD were monitored using respiratory inductance plethysmography and metabolic gas analysis. After 4 minutes of natural breathing, subjects completed 2 minutes of DB followed by 4 minutes of natural breathing. Dyspnea was measured using a visual analogue scale. Diaphragmatic mobility was assessed using chest radiography. DB was associated with a significant increase in tidal volume and reduction in breathing frequency, leading to higher ventilation and oxygen saturation, with a reduction in dead space ventilation and ventilatory equivalent for carbon dioxide. A total of 10 subjects with moderate (5) and severe (5) COPD performed DB with asynchronous thoracoabdominal motion, worsening the dyspnea, and decreasing the gain of tidal volume. Diaphragmatic mobility, inspiratory muscular strength, lower scores for dyspnea and hypoxemia as well as coordinated thoracoabdominal motion are associated with effective DB. In patients with COPD, DB can improve breathing pattern and ventilatory efficiency without causing dyspnea in patients whose respiratory muscular system is preserved.

Daily activities are sufficient to induce dynamic pulmonary hyperinflation and dyspnea in chronic obstructive pulmonary disease patients

OBJECTIVE

The aim of this study was to measure dynamic lung hyperinflation and its influence on dyspnea perception in moderate and severe chronic obstructive pulmonary disease patients after performing activities of daily living.

METHODS

We measured inspiratory capacity, sensation of dyspnea, peripheral oxygen saturation, heart rate and respiratory rate in 19 chronic obstructive pulmonary disease patients. These measurements were taken at rest and after performing activities of daily living (e.g., going up and down a set of stairs, going up and down a ramp and sweeping and mopping a room).

RESULT

The inspiratory capacity of patients at rest was significantly decreased compared to the capacity of patients after performing activities. The change in inspiratory capacity was -0.67 L after going up and down a ramp, -0.46 L after sweeping and mopping a room, and -0.55 L after climbing up and down a set of stairs. Dyspnea perception increased significantly between rest, sweeping and mopping, and going up and down a set of stairs. Dyspnea perception correlated positively with inspiratory capacity variation (r = 0.85) and respiratory rate (r = 0.37) and negatively with peripheral oxygen saturation (r = -0.28).

CONCLUSION

Chronic obstructive pulmonary disease patients exhibited reductions in inspiratory capacity and increases in dyspnea perception during commonly performed activities of daily living, which may limit physical performance in these patients.

State of the art: how to set up a pulmonary rehabilitation program

Pulmonary rehabilitation plays an essential role in the management of symptomatic patients with COPD. The benefits of rehabilitation include a decrease in dyspnoea and fatigue, and improvements in exercise tolerance and health-related quality of life. Importantly, rehabilitation reduces hospitalization for acute exacerbations and is cost-effective. Although most of the evidence for pulmonary rehabilitation has been obtained in patients with COPD, symptomatic individuals with other respiratory diseases have been shown to benefit. In this review we outline a stepwise approach to establish, deliver and evaluate a pulmonary rehabilitation program (PRP) that would be feasible in most settings. Throughout the review we have specified the minimum requirements for a PRP to facilitate the establishment of programs using limited resources. Recommendations for staffing and other resources required for a PRP are presented in the first section. Exercise training is a focus of the section on program delivery as this is the component of rehabilitation that has the strongest level of evidence for benefit. Program considerations for patients with respiratory conditions other than COPD are described. Different approaches for delivering the education component of a PRP are outlined and recommendations are made regarding topics for group and individual sessions. The problems commonly encountered in pulmonary rehabilitation, together with recommendations to avoid these problems and strategies to assist in their resolution, are discussed. The review concludes with recommendations for evaluating a PRP.

A telemedicine instrument for Internet-based home monitoring of thoracoabdominal motion in patients with respiratory diseases

Changes in thoracoabdominal motion are highly prevalent in patients with chronic respiratory diseases. Home care services that use telemedicine techniques and Internet-based monitoring have the potential to improve the management of these patients. However, there is no detailed description in the literature of a system for Internet-based monitoring of patients with disturbed thoracoabdominal motion. The purpose of this work was to describe the development of a new telemedicine instrument for Internet-based home monitoring of thoracoabdominal movement. The instrument directly measures changes in the thorax and abdomen circumferences and transfers data through a transmission control protocol∕Internet protocol connection. After the design details are described, the accuracy of the electronic and software processing units of the instrument is evaluated by using electronic signals simulating normal subjects and individuals with thoracoabdominal motion disorders. The results obtained during in vivo studies on normal subjects simulating thoracoabdominal motion disorders showed that this new system is able to detect a reduction in abdominal movement that is associated with abnormal thoracic breathing (p < 0.0001) and the reduction in thoracic movement during abnormal abdominal breathing (p < 0.005). Simulated asynchrony in thoracoabdominal motion was also adequately detected by the system (p < 0.0001). The experimental results obtained for patients with respiratory diseases were in close agreement with the expected values, providing evidence that this instrument can be a useful tool for the evaluation of thoracoabdominal motion. The Internet transmission tests showed that the acquisition and analysis of the thoracoabdominal motion signals can be performed remotely. The user can also receive medical recommendations. The proposed system can be used in a spectrum of telemedicine scenarios, which can reduce the costs of assistance offered to patients with respiratory diseases.